All right, thank you so much, Dr. Lawson, for helping us set the stage and kicking off this important convening. We have a jam-packed day set for you, so we're going to jump right in with our first session. I would like to introduce our two esteemed panelists, Dr. Neil Krishan Agarwal and Dr. Pooja Chadha. Dr. Agarwal is a professor of clinical psychiatry in the Department of Psychiatry and a member of the Committee on Global Thought at Columbia University. He is also a research psychiatrist at the New York State Psychiatric Institute and a cultural psychiatrist and social scientist. Dr. Agarwal has over, Dr. Agarwal is the author of over 100 peer-reviewed publications and five peer-reviewed books. He is, he has, his work has been published in journals such as JAMA, New England Journal of Medicine, the American Journal of Psychiatry, JAMA Psychiatry, Medical Anthropology, Medical Anthropology Quarterly, Social Science and Medicine, and Culture, Medicine and Psychiatry. Welcome, Dr. Agarwal. Thank you very much. Thank you. Good morning. Good morning. Oh, there we go. Can we have a round of applause for the American Psychiatric Association and for the AV folks in the back? I'm really grateful to be here today because the number of spaces where we can have this kind of conversation, I fear, are shrinking. So these are my affiliations. And I appreciate that Dr. Lawson introduced the idea of our political environment. If you're going to open that door, I'm certainly going to walk right in. And so what I'd like to do is talk about the evidence base behind one of the tools that was just mentioned around the cultural formulation interview. And I've spent much of the past 15 years developing it with a team of international collaborators. And we'll go through a quick dance through some of the evidence base there. I promise I did not pay Dr. James or Dr. Lawson for their slides, because they've really helped me lay the foundation for much of what I want to present today. So if I can find a way to advance this. Oh, there we go. So these are the educational objectives for today. Hopefully, we are going to understand the DSM-5 TR conceptualization of culture. We'll talk about sources of disparities. And I won't reiterate what has been said. But I'll try to give you a different way of thinking about it. We'll talk about the cultural formulation interview field trial and the evidence base. We'll talk about the rationale for the core CFI's questions. If you have your brochure in front of you, two out of the three pages of the CFI have been printed there. And so I'll give you another resource in the midst of our presentation for you to be able to access. And we'll talk about how the CFI has affected care. So first thing, what is culture? What is a sociocultural assessment for clinical care? Why do a sociocultural assessment in routine care? Now, I'm not a psychiatrist. And the social science that I tend to draw upon most is medical anthropology. And so if you sit in a room of anthropologists, everybody will quibble about different definitions of culture and how it gets operationalized. What I love bringing out with that community, for many providers, it can be a challenge to think about cultural-related work on a one-on-one basis with patients and then to be able to provide questions that elicit pertinent answers. And so we'll talk about that as well. We'll go through the development and content of the CFI and key implementation questions. Finally, I'll read some conclusions, hopefully that might be helpful for you all. First, how do we think about culture in clinical work? So in DSM-5-TR, I, along with other folks in the DSM-5 cross-cultural issues subgroup, we're trying to think about ways that all of you who see folks in your practice might be able to do something useful with culture. None of us are gonna be like anthropologists, perhaps, who will spend anywhere between 12 and 16 months in immersive fieldwork, studying the practices, the social institutions, the patterns of kinship that other people end up experiencing in order to understand what makes them human. We might have 50 minutes in an intake. And so how does one think about compressing the kind of work that might be clinically applicable without being able to have immersive fieldwork experiences? And we define culture as the processes through which people assign meaning to experience, drawing from values, orientations, knowledge, and practices of the diverse social groups in which they participate. This point here is really critical, right? Because from the late 1990s through until about the 2010s, people would talk about culture in these broad settings, right, like racial and ethnic minoritized groups. But now we also have a counter-literature talking about intersectionality or hybridity. So how do we think about the different social groups that people belong to, but at the same time, recognize that the person in front of us is at the unique confluence of how those groups endow that person with a sense of identity and a way of being in the world? It's aspects of a person's background, experience, and social context and position that may affect their perspective. And when we talk about perspective, we're talking about health, illness, conceptions of suffering, conceptions of treatment, who should be involved in healthcare or not. And we also talk about the influence of family, friends, and other community members, right? Because as everybody knows, culture is not just received, it's also transmitted intergenerationally, horizontally, based on who's around. And people create culture just like they receive it. And that's really important for us in thinking about treatment preferences or how they understand their causes in any given illness experience. And finally, as somebody who writes in anthropology journals for a living, I'm very interested in power-knowledge relations. And one thing that we tend not to talk about, though I think this room is more predisposed to sharing my viewpoint, is that how do we talk about the ways healthcare providers are formed? What is their form of knowledge? What are their forms of practices that are embedded in the organizations in which they work? How do they practice? And how can that actually affect the clinical interaction? And how do we start getting providers to reflect deeply on the fact that they might be the source of disparities? As opposed to assuming, well, I can just ask a bunch of questions, I'll get this brief cultural information, but disparities are what other people do because I'm just too awesome. I'm too evidence-based, right? How do you promote that sense of critical reflection to say, well, where am I in this process and how do I make sure my work mitigates rather than exacerbates disparities? And what I've been trying to encourage people in my practice communities is to say, well, for so long, culture has kind of been a one-person model, like this is what they have. How do you think about culture as an intersubjective process in which you are also embedded? So as we know, as Dr. Lawson made out the case, disparities affect minority groups throughout the entire mental health services pathway. Some of those key disparities are already identified, but as you can see, when we talk about risk factors, we're all more and more talking about structural and social determinants of health. We're talking about how people recognize their symptoms and impairments. We're talking about how people assign meaning to what's going on with them. Is this a spiritual problem? Is it something that I need to seek professional help for? We're talking about forms of self-coping, like what they do outside of the healthcare system. We then talk about access to care. And finally, like here in purple, where all of us who are involved with the DSM effort understand very deeply, we're talking about the diagnostic evaluation, right? So like all this work happens that people engage in, like before they even reach the clinic, right? Before they finally get to access and care and the diagnostic evaluation. But you're already seeing disparities in risk factors, in illness interpretations, and how people engage in various resources for self-coping. And then afterwards, we talk about treatment choice, treatment goals that people might have, treatment participation and treatment retention. If you want to talk about the business case for closing disparities, as many people might know, some of the quality indicators are adherence to medication, adherence to appointments, right? How are you going to get people to come back to your clinic and adhere to treatment, attend appointments, adhere to treatment plans if you don't close disparities, right? Or if they feel misheard. So my goal with this slide is to suggest to you that disparities affect the entire mental health services pathway, not just a single point in time. So how do we do a sociocultural assessment? So we believe that it's the process of eliciting, organizing, and interpreting information on the impact of culture and social context on the person's social network, the person and their social network's views about health and illness, practices about health and illness, and resources pertinent to clinical evaluation and treatment planning. And it can be systematic or ad hoc. We prefer a systematic assessment. Why? Because it can be comprehensive, it can be skills-based, and when I speak to people where the melanin count is a lot lighter than what it is today, that I'm telling them it's skills-based, it's not ideology. Like if somebody from a European ancestral background walks into my clinic, even though they might be in the majority in the population, it's still a cross-cultural encounter, right? And those folks need amazing care just like everybody else does, right? So it should be skills-based, it should be thorough, it should be person-centered. How do you go and kind of perform the alchemy of thinking about groups in which people belong to then thinking about the intersectional set of identities for the person in front of you? It should be standardized, ideally, so that way you're not missing things, and it should be educational because this is like the first kiss to a long romance of self-education. It's not one and done, right? It should be a lifelong process of skill development, just like everybody has to get CME in medication management or in psychotherapy every three years. In my other publications, I suggest that cultural assessment, cultural competence work, understanding models of culture and how they change is also a lifelong process of skill development. Now, why should you conduct a sociocultural assessment? Well, for many people in the room who have participated in the DSM enterprise, it's because it can guide diagnostic translation. As we know, culture affects how people interpret what's going on with them in terms of their distress, how they communicate that to the provider, and then what the provider does in the chart or in the interaction or in a team-based setting. So it affects the experience that people have internally and how they communicate it externally. And then as anybody who has ever spent time trying to diagnose understands very deeply, there can be significant challenges in trying to translate what somebody tells you in an interview, and then finding like the right DSM diagnosis or category to perform that clinical translation, right? You're talking about lay translation of language into the professional language of diagnostic frameworks, and healthcare. And then ideally what it can do is with listening to the person's narrative, it can actually transform the clinical encounter itself where instead of just going through, and I'll never forget how in the DSM-5 field trials, I saw, as we were trying to introduce the CFI, somebody who was a clinician meeting with a new patient and was videotaped, and it was like just SIGECAPS, right, for major depressive disorder. The clinician was like, are you experiencing any sadness, any loss of interest in things you like to do, any guilt, any loss of energy, any loss of concentration? I was like, whoa, all these like close-ended questions, right, there was no room for the person to be able to speak, and it was just yes or no. But like those kinds of symptom checklist appointments can be transformative if people are given tools, and it can be a way to rethink the kind of work or the labor that's done in the clinical encounter. We believe that it can elicit person-centered information where you're trying to understand someone's views about illness and care, specifically in helping them co-construct a narrative, and how that individual fits within their social or structural context. In this current political environment, since there are some spaces where we can't use words like equity or equitable, I've moved now to thinking about how we might be able to play with two types of concepts, the person's intersectional identity within social determinants of health. So far, those terms haven't been identified as politically divisive, but we'll see. It can increase rapport and trust, enhance alliance. We can create treatment plans that align with people's expectations, and we can help empower patients. So let's talk about how the Cultural Formulation Interview attempts to do this. The DSM-5 Cultural Formulation Interview that I and others worked on are a set of interview protocols that can help providers find a voice to these kinds of questions in doing a cultural assessment for any provider in any care setting. And the center where I work at Columbia led its development inclusion in DSM-5. And these are the various sites around the world that we tried to include, so that way we would have broad provider and patient variation, not just in terms of race and ethnicity, but also in terms of rural-urban status, or also in terms of language. And there are different CFIs that people can use. There's a core CFI that consists of 16 questions that we're going to breeze through today. There's an informant version for people who are working with different types of populations, whether it's children and adolescents, whether it's older folks who might have cognitive impairments, whether it's folks who are acutely intoxicated and there are informants who bring them into care. And then there are 12 supplementary modules that expand the topics in the CFI. And the DSM-4 outline for cultural formulation that was introduced in 1994 had five domains in the outline for cultural formulation that the cultural formulation interview then converts into questions. One of the biggest criticisms that we got about the outline for cultural formulation is that it's a list of social science topics that people don't necessarily know how to use. So we decided to convert those into a set of 16 questions after significant beta testing with patients and clinicians and these are the domains that can be crosswalked with the CFI. So this is for all the naysayers who typically are people who disagree with this kind of work, that this is the way that we came through a stepwise evidence-based iterative process of developing the CFI. We reviewed all the literature on the OCF. We reviewed all cultural assessments in databases in psychiatry, psychology, and social work from 1994 to 2011. We looked at common areas of cultural assessment, drafted a 14-item beta version. We developed a training approach. We tested it in the field trial with the fancy slide that I showed you a few slides ago with the nice colors in different parts of the world. And the numbers don't lie, check the scoreboard, right? Six countries, 11 sites, 321 patients, 75 clinicians, 86 family members. We revised it. We reported field trial findings in a stepwise fashion and we included it in DSM-5. As we said, it can be used by any patient and any provider in any setting. You can start it for kicking off your general interview in a first appointment or at any point in care and we believe that it's particularly interested in cases for cultural differences where you feel like you're not able to understand the person in front of you, where you think there might be a challenge in the fit between what their symptoms are and what the DSM categories are, when there might be difficulties in understanding levels of impairment and severity, which is like one of the criteria for all DSM disorders. It's especially helpful for anybody who does work in the forensic system. Whenever patients and clinicians frankly disagree on the course of care and whenever there's limited treatment adherence, right? People are just not showing up to appointments or if they're not adhering to a treatment plan or if they're not engaging in social services that you might refer to. And the parts in these two bullet points are what we also added in DSM-5-TR when there can be divergent views and expectations due to previous care experiences and since that door was opened and we know that there's a whole lot of red and that white and blue, as some people have said recently, whenever there's mistrust of services and institutions from past trauma and oppression. This is the structure of the core CFI. I'd like everybody, if you can, to take a minute, take 10 seconds actually. If you can open up your mobile device, go to Google and type in seven characters. First, APA, American Psychiatric Association, and CFI. So APA, spaced, CFI. The first link that will pop up is the cultural formulation interview. When everybody is done, please raise your hand just so that way I know that we can pace. Great, so that wasn't too terribly difficult. And what you will now see is an interview that we helped to develop that's in DSM-5 with all the evidence base that I showed you that you can use today or tomorrow or the next time you have a clinical encounter. So this is the structure of the core CFI. It's like a SCID where on the left side there are instructions to clinicians and on the right side are the actual questions of the CFI itself. Let's go through this quickly. So the first domain is what we call the cultural definition of the problem. It's how the person uses language, the person in front of you, in their own way to be able to express their form of distress. It's also how we ask them to tell us how they refer to that distress to other people in their social network and what most troubles them about it. This is critical. In the introduction to the CFI, we emphasize certain points, like we ask providers to articulate that they're trying to understand how to help their patients most effectively. We want to know about your experiences and ideas. We're going to be asking some questions about what's going on and how they're dealing with it and that there are no right or wrong answers. I have a paper published in Anthropology and Medicine from like 2020 where we looked at different medical communication paradigms across all medical specialties and signposting as well as offering nonjudgmental statements of assurance are key communication behaviors that providers can adopt, no cost, free, easy ways to build rapport right from the outset. Cultural number one, or question number one, you can read along if you have it open. How would you describe what's happening to you today? And if you feel like people are using biomedical terms, you can say, well, people often understand their problems in their own way, which may be similar or different to how doctors understand their problem. How would you describe your problem? Question number two, how would you describe your problem to your family or friends or other people in your network who you care most about? Because we recognize that culture is inherited and transmitted across social groups, we are privileged to be bystanders in someone's life for about 50 minutes. We're not gonna be able to do that immersive field work necessarily in a community-based setting. So this is a proxy question that we can get at to see how people understand their experiences of health and illness in the community. Number three, what troubles you most about your problem? Now let's go to the second domain, which is cultural perceptions of cause, context, and support. Question four, what do you think are the causes of your problem? Because many of us know that the ways that people ascribe causes to their problem affects how they think that problem should be treated. And then how would you other people in your family or friends or community think are the causes of what you're going through? Questions six and seven are about social supports and stressors. What kinds of help have you received from other people in your family or friends or in your community? And what kind of problems have you experienced? And now let's get right to the heart of the matter around intersectionality. Questions eight, nine, and 10 free, in my opinion, the provider from having to project an identity onto the patient. Because I might look like a brown person to you, but I come from a half-Hindu, half-Sikh family, where I have criminal justice involvement personally. I've been arrested. I don't know if anybody here has been arrested. Nobody wants to talk about sharing experiences in criminal justice. Thank you very much, brother, for raising your hand, right? But, I mean, many people who are brown and black have experiences in the criminal justice system unwillingly, and if you don't ask them about it, they're not going to tell you, right? And I'm a father. I'm a professor. I'm a husband, right? But figuring out what aspect of identity is most pertinent in a clinical encounter is the challenge that many of us face. And assuming that it rests only on race or ethnicity is, I think, a real damage that we do to our patients. So question number eight begins with a quick intro. Sometimes people... Right now I'd like to ask you questions about your background or identity. By background or identity, I mean languages that you speak, where you or your family are from, your race or ethnic background, your gender or sexual orientation, and in a shout-out to the last question that was asked after the session, your faith or religion. Question number eight, for you, what are the most important aspects of your background or identity at the moment? Question number nine, how do those aspects of your background or identity relate to what's going on with you and your problem? Then question number ten, how do aspects of your background or identity cause other challenges for you in your life? Here in question number ten, for example, in our clinical work that we've published, we see that folks who are undocumented or having issues with intergenerational trauma, that those might be really important life stressors to ask about, but that they're not necessarily how somebody self-identifies, and yet they can mean, like, a fundamental difference in how people access care or social services. Now, the third domain is on asking about coping and help-seeking. So, what have you done on your own to address this problem? Question number 11. Question number 12, what kind of help have you sought for this problem in the past? And by help, I mean different kinds of doctors or helpers or healers, and what was most useful, what was not? That, in our estimation, is actually clinically helpful information that might be used in informing your ongoing treatment planning. Question number 13, and the reference here is to a paper that might be of interest to this community, which is a paper that we published on how this question in particular can elicit social and structural determinants of care in a person-centered way. Have there been any issues that you've experienced in being able to access care? Like, for example, difficulties with money, or maintaining work or family commitments, or stigma or discrimination, or a lack of services that understand your language or background? Final domain goes into the current help-seeking encounter. Now, let's talk about the help that you need. What kinds of help do you think would be most useful to you at this time? Question 14. And then, again, because culture is shared in social groups, question 15 is, what kinds of help do your family or friends or other people in your community think would be most useful? Then the final question, which some people don't want to talk about, is that sometimes doctors and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about this, and is there anything that we can do to provide you with the care that you need? I get so much pushback on this question, and I can tell you when I've taken this to Jamaica Flushing Hospital Medical Center in Queens, which is the most diverse zip code in the country, and we did my pilot NIMH K23 award there, out of 32 patients, is it 32 patients, something like that, over half of new patients will tell you that they have doubts about being able to trust the provider or they feel ambivalent about it right from the first session. So the title of that paper is, If You Don't Ask, They Won't Tell. Now, let's talk about some questions on how to implement this. How easy is it to implement it? We can show you from the field trial. Again, Tom Ford, the numbers don't lie. Check the scoreboard. 321 patients, 75 clinicians, 86 relatives. We can show you that CFI has high feasibility, acceptability, and clinical utility if you're looking at implementation science paradigms. What are the kinds of mental health services, outcomes that people tend to look at in introducing new innovations in service pathways? This interview can be conducted in about 20 minutes after one practice run. And so the question that keeps coming up over and over again for anybody who's been SAMHSA or AHRQ or NIMH funded is, how do you bridge the science practice gap, right? So as we're going through this, please think about your own practice settings, and if you have any doubts or barriers that you want to share in the Q&A, I've heard it all. I'm happy to help troubleshoot with you. Here are some field trial results and some nice-looking slides. We see when you look at clinicians versus patients across the board, when given Likert answers, that patients find it more acceptable, more feasible, and more useful than clinicians do. Why? Because patients get to share their story. We'll go through that in just a second. More importantly, clinicians will give us the range of excuses. I don't have enough time. I don't think this is helpful. My patients don't need it. I'm, like, superstar clinician anyway, so I know all this. Yeah, we heard it all, right? Here is a slide that looks at interview duration. In the field trial, we asked people to do between three and six interviews. We wanted people to do at least three because if they did one and they totally hated it, then that doesn't seem like it would be representative data because whenever DSM introduces new changes, people don't just get to use it once and then discard it, right? It's a process of ongoing training, education, and commitment. We didn't want people to do more than six interviews so that we could broaden the clinician pool. We can show you that from the first interview where the CFI took 26 minutes and an overall 62-minute duration for the appointment, that by the third appointment, they were able to shave off nine minutes of the overall interview and four minutes from the CFI. The more they did it, as you can see, by the sixth interview, they were able to do it comfortably within 50 minutes, and the CFI took about 22 minutes. We have been able to show that the reason why is because people end up asking nonsensical questions in the social history, in the past psychiatric history, in the family history that they learned from textbooks that were written like 50 years ago that aren't customized to the person in front of them, right? And here you're doing a person-centered assessment in a really targeted way. Now, how do clinicians like being trained in it? In the field trial, we asked everybody to read the CFI just like you might have access to right now on your phone. We went through different workshops that were passive versus active. Passive is getting some person like me droning on and on. Whether you're paying attention or not, I have no clue, right? You could be thinking about what's going on at lunch, when is this guy going to stop, right? I have no idea how actively you're engaged in this material. Active training methods, if you look at studies of like adult pedagogy, are when people are forced to engage in actually incorporating information and translating it into practice, like case-based simulations, for example, or like question and answer sessions or small groups. We can show you in the training package when we went through different types of ways that clinicians prefer to be trained in the CFI that behavioral simulations and video were the best. Video is passive, but it provides ways of modeling how to use CFI questions in practice, and behavioral simulations allow providers to be able to practice the questions in their own voice. Now, what is the CFI useful for? Re-diagnosis. We can show you that when 70 patients with an initial diagnosis of psychosis went through cultural formulation, 49% went from a psychotic to a non-psychotic diagnosis. Half the folks in a cultural consultation service were re-diagnosed. This is like the difference between starting somebody on an antipsychotic medication with all of the different neuromuscular effects, if you're thinking about the older ones, or the cardiovascular, cardiometabolic effects, if you're thinking about the newer antipsychotics, right? Committing a person to a higher threshold of risk-reward side effects versus therapeutic effects versus other types of treatment, re-diagnosis. And interestingly, we don't see the opposite, right? People with a non-psychotic disorder were diagnosed less frequently with a psychotic disorder. The point here is that when we know that there are so many disparities in brown and black folks being diagnosed with higher rates of psychosis versus non-psychosis, we now finally have one intervention that can help to change that conversation. What did patients versus clinicians think the CFI was doing? What kind of work clinically was it accomplishing? The purple is the patient. The purple is the clinician. Because, as was just mentioned in the last presentation, that patient satisfaction is a key quality indicator, over 80% of patients felt that use of the CFI was able to enhance rapport. And when I take a look at that, or look at the one below that, allow clinicians to express caring. Clinicians tend to be thinking more at the cognitive or informational level than patients who are looking at the more emotional level. What do clinicians think it's helpful for? Enhancing the patient's perspective. Enhancing communication. Increasing their understanding of illness. And we can see a clear difference that the same set of questions and answers in the same encounter does, like, really different work depending on how people are structured in terms of power in the clinical encounter. That's, like, fascinating to me. So this is work that I tend to present in more hostile audiences in NIMH-funded settings, which is when we take this into the community, and I have this underlined to show you just how diverse our predominant sample is in Queens, that when we take the CFI and test it compared to treatment as usual, and this is, like, a very enlightened clinic in Queens where most of the providers are brown and black or Asian, and the patients are all, for the most part, brown and black or Asian, right? So it's a really hyper-diverse setting. And we ask people to do CFI questions, and the engagement aid that I develop is to say, well, you have all this information. Now how do you use it? How do you document it in the electronic health record? How do you inform your treatment planning? So there are a set of questions. You can Google CFI EA in my last name, and you can get it for free because it's all we make all of our work available for free because it's part of our federal grant guidelines, right? And what we can show you is that all patients, when you look at them compared to three sessions, attend session one, we start to see differences in session two, but then by session three, even in a small group, that patients in the treatment-as-usual arm start to drop out more compared to CFI EA patients. And then this is what I mentioned to you in the last blow point here, which is that more than half of patients presenting to established care were able to express mistrust or ambivalence towards their clinicians right from the outset. This is like minute 15 of their first interview in the first clinic. When people are given an opportunity, they'll be very honest. So what are some areas that we need more research on? If you look at CFI studies, several points start to, I think, become clear. First is, how effective is it to do all 16 questions in a row versus tailoring them or using certain questions at certain points in care versus other questions? Second, and because I have to, like, dance for my pay at NIMH, and they're all cared about, outcomes. What are the outcomes to measure? Folks like me, and maybe I'm, this is like my social science hat on, I actually think there's real value in enhancing rapport for people to be heard. NIH folks want changes in diagnosis or the cost business case. Yeah, the business case is important, but, like, I mean, I also recognize that we belong to a capitalist healthcare structure that has so often oppressed people who are poor. And the business case might be necessary, but it's not sufficient, right? Compared to, what are we testing the CFI against when we're thinking about clinical trials? Is it usual treatment? Is it people who have some training in cultural competence? Is it to an in-depth cultural assessment? How do we think about some of the unresolved questions in community practice, like team-based care? When we start to involve interpreters or cultural brokers or peer providers, who does what in a team-based setting, we see more and more that social workers end up using the CFI or psychologists end up using the CFI because psychiatrists tend to see themselves as not needing to ask questions about culture or social influences, perhaps because providers like psychiatrists are incentivized to do medication management in the current healthcare structure. There's been a lot of great work in medical anthropology and medical sociology about how, with the introduction of managed care in the 1990s, that, like, all of the touchy-feely social cultural labor went to social workers and some psychologists, and all of the so-called hard biological science-related labor went to psychiatrists. And then, unfortunately, CMS funding shows disparity or differences in how those reimbursements pan out based on discipline. How do we think about continuity of care, like translating those questions and the information that's elicited when patients go from inpatient to outpatient, or urgent care to outpatient, or standardized versus flexible use, as I mentioned before? How do you record this information in an electronic health record? Finally, how do we start thinking about, like, ways of adapting questions for populations where they just are fundamentally invisible if you look at scholarship, right? We don't see the cultural needs of children and adolescents addressed in scholarship in a way that we know at a population level that those are supremely important. And when you look at cultural assessments for school-age children or adolescents, that, like, there are so few studies done on this population that that's a huge gap. Same thing with older folks. It's like folks after 70 are just absented in scholarship. Why is that? Like, what have we, like, as a society, have we just forgotten about prioritizing elders in our community? And then how do we start to think about ways of incorporating social and structural determinants of health? So what I've tried to do today is convince you, though I don't think many of you need it so much convincing, that there's value in doing sociocultural assessments and trying to kind of reimagine what the clinical encounter looks like in a person-centered way. I've tried to suggest to you that some of the work that we've done in the DSM-5 cultural formulation interview is one step in that direction. I am more than aware of all of its limitations. As somebody who has helped to develop this, I like, in my capacity as an ethnographer and social scientist in clinical settings, I like thinking about ways that we critique power structures, including the DSM and the knowledge that's produced in the APA or other professional organizations. People saying, well, how is this really responding to, like, our most disadvantaged patients? And then how do we think about combining the CFI's information with other modalities? I'm pretty interested in, like, exploring this when it comes to medication management and psychotherapy and seeing how it might change some of the core clinical tasks that providers have to engage with. And then how do we start to develop the business case, because I know that all of us have to bill, and showing clear changes, whether it's Z-codes, which we have some more coming out showing how Z-codes can really, really customize social determinants of health assessments for individual patients. But then if you're thinking at the systems level, that institutions and networks can aggregate Z-codes based on their catchment area to be able to lobby for greater funding, and that might be a way of closing disparities. And at this point, whoops, I'm happy to take any questions or answers briefly before. What? Okay. So I'm being told that Bhuja should present next, but thank you very much for your attention. And we'll catch up at the Q&A. Thank you. Thank you so much, Dr. Argyle. I know you have a ton of questions, but if you can please hold them to the end. I would like to introduce Dr. Chadha. Dr. Chadha is an Associate Clinical Professor in the Department of Psychiatry and Behavioral Sciences at UC Davis. She serves as an Assistant Training Director for the Center for Reducing Healthcare Disparities, as well as multiple teaching roles in the School of Medicine and Psychiatry Residency Training Program Director for Diversity Education, Office of Faculty Development and Diversity Leading Curriculum to improve faculty, supporting inclusion for diverse students, as well as training on faculty search committees, training diversity and inclusion efforts, and in workforce recruitment. Clinically, Dr. Chadha has worked with UC Davis and, I'm sorry, clinically, Dr. Chadha has worked with UC Davis Psychiatry and later moved on to work with underserved populations through the county medical health clinics in Sacramento. She was an active team member for the 2017 Dean's Team Award for Inclusion and Excellence for her work on class implementation and community engagement longitudinal collaboration projects at the Center for Reducing Healthcare Disparities, and she was one of the faculty inductees to the Goal Humanism Honor Society in 2018 for the University of California School of Medicine. Dr. Chadha, welcome. Good morning. How is everyone doing? I want to thank you for sitting this long, and I'm going to try and make this interactive to tie in to what Dr. Lawson was talking about, which is the business side and the appeal of this information. So, my name is Pooja Chadha. Thank you for that kind introduction. Thank you, everyone who has gone into creating this opportunity. These are some of my credentials, but my biggest credential that I bring today is that I am a fellow human. So, I want to thank you first. I want to borrow from Dr. Jambree Garcia and Dr. Melanie Trevilon, who coined the term cultural humility. One thing that Dr. Jan has taught me, I've had the privilege of working with her at UC Davis, is that it's not if I make a mistake, it is when. I hope you will give me the gift of letting me know so I can be better. That is really something that I want to lead with today, and I'm here to work with you. You all are amazing folks to even come here today. You are our change agents. The goal today, these are my disclosures, the goal today is to find one piece that might work in your endeavors, and we really want to customize it to what you're trying to do in your individualized settings. So, we're grounded that we all bring different things. We come with our own web of understanding of these things, and we all bring different perspectives. So, we want to put into action, I want us to think, how can I make this effective in my work, or in my system, with my teams? So, just a quick highlight of what's already been covered. According to the World Health Organization, health inequities are measurable differences in health across populations. Health disparities are preventable differences in burden of disease, injury violence, or opportunities to achieve optimal health, according to the CDC. So these are national organizations you can lean upon. I am going to focus on how we look at the change. Think of what level you're trying to make the change at. Is it your own individual or at an individual's? Is it interpersonal communications? Is it locally within your clinic or within your department? Or is it system-wide or is it nation-wide? We talk about the fund of knowledge, and that is critical. I appreciate each amazing speaker that's coming to give you that fund of knowledge. I'm going to go into the how and the what that we do these conversations, because what are the challenges of actually bringing this information to national dissemination to actually be used? I want us to think on that a second. What's a challenge? Anyone want to give a shout-out? Okay. Polarized world. Yes. What else? What about having these conversations? Are they easy? No. So what I have today is a potential framework that we can use to help people have those conversations. There are some folks we work with who just don't know how to have these conversations and preserve their dignity. It's really hard for them. And we want to foster a space that it's easier to have these conversations and that they actually enjoy it. Just want to highlight a couple aspects of class, and thank you everyone who has mentioned it before. Class is about respect and how to respond to individuals' needs and preferences. And if you need the full class credentials, go to Think Cultural Health. The website's there. And I fully invite you to really look at those and embed them into your system's work. It is a good criteria to really use when you're arguing rationale within your system. The first principle standard is to provide equitable, understandable, and respectful quality of care with services that are responsive to diverse cultural beliefs and practices with preferred language, health literacy, and other communication needs. I wish I had time to go through all of them. I'm going to pop them up on the screen so you can get them. But I really want you to spend time with them at a different time to go through them. I want to get to the how and the why. But briefly, it ties into governance and leadership, workforce development in the first, in the two, three, four. It talks about communication. We've already been dialoguing on this. Multimedia, spoken, signed, written. Even when they call the line for the intake, is there someone at the other end who's willing to understand them in a language that makes sense? Is there signage that's making them even want to come through the door, let alone come back? Then there's communication and language assistance, which ties into that previous slide. And here are the tenets of those. There's 14. We then want to work at how do we engage with folks? How do we engage in our system? How do we have accountability? How do we build it in? And that is highlighted here in nine through ten. It also includes generating a workforce, which is the next step. Really looking at systems change and policy are the next step. So I'm going to go to there. Governments and leadership. We need to partner with our community. We can't just give what we think people need. We need to give them what they truly need. How do we find that out? Yes. We ask them directly. And then here's the tricky part. What happens when they say, yeah, there is a problem? We need to feel comfortable and have an algorithm to really address those in a meaningful way. So we were talking about the business side of things. I'm really glad we went there because here are some business components. We can mitigate and eliminate health disparities. We can improve patient-provider communication. We can enhance quality of care. It feels good when you use the CFI, when you use class standards. It feels good because you're more connected. It does promote cultural competency. There's also, if there's people who are on the fence about whether or not they buy into this, you can argue that there's legal compliance. Better rapport can lead to reduced malpractice. The other component is it's cost effective for your system. The amount of ED return rates decreases as you actually save money having interpreters. When you look at the cost, the highest cost individuals that come into an ED are actually the ones that are English speaking, believe it or not. Then when you introduce interpreters, there's improved continuity of care and better chances they will end up at the clinic rather than returning to the ED. When you're trying to generate your diverse workforce, if you can create, using class standards, a sense of belonging, you will decrease the costly staff turnover rate as you try to maintain and sustain that group. So there's a lot to say about class, and I highly encourage us all to adapt these into our work. But I promised you I was going to talk about a rubric of how do we help others have these conversations. Let me give you one example of some work that we've been doing at UC Davis that has now gone national. So I first of all want to thank the students, the medical students that helped found this, and a number of amazing individuals, Office of Health Equity, my grant team, and then my department chair, my educational chair, and the person who made it possible to market. So we're going to go through these. Because we don't have enough time, and I kind of guessed that we might, I thought we could do it in the form of Jeopardy because I want us to be interactive. Would that be all right? Okay. I'm going to need a little help though, because the stars are things we definitely have to get through. So bear with me. Is it okay if we go through the right-hand most three, and then we can go anywhere? You good with that? Okay. So let's make it a little bit of fun. If we could go with, the top says what, and the next one's how, logistics, does it work, and impact. So if we could go for $40,000 for the rationale, please. So what was the rationale of AID? AID is a course that stands for Advancing Inclusivity and Diversity. It was founded based on issues that students found, and the original course was supporting educational excellence and diversity. I don't know why diversity is missing, I apologize. And we founded it actually in 2018, but it became a formal course at UC Davis in 2019. LCME, we actually had a citation on this area. Students were experiencing harm in not only the patient care they saw, but also in mistreatment related to microaggressions. We actually had a student-driven grant, and we led to systems change. I'm going to get into actually how. Tracking from 2018 until now, actually 2020 until now, we see a shift in the graduation questionnaire for the medical students. And in the specific reports that we have, looking at how we're dealing with specific populations of our students. We have increasing diversity of students that we are able to recruit for our medical school. Now we're working on building a home for them that they truly want to stay in. Okay, so if we could click the image. Thank you. Is it okay if we go to what is it for $10,000? We good? Okay. So what is a... Can we click on what is it? Thank you. Okay, so I really want to be grounded to how do we give this conversation to people? Like I said, we're in a polarized world. How do we get everybody engaged? And some folks who are like, I don't like certain words. How do we get to that conversation? Well, we need to encourage them to get a core fund of knowledge. This course gives some foundational knowledge. I'll go over that. We have concrete tools and strategies to manage those difficult situations. We want to understand the impact of power dynamics in what we're doing. And then we want to deepen emotional intelligence, professionalism, and skills for self-management from the interpersonal level to the departmental to enacting systems change. We want to give them all the tools to think it through, but also not make them a target and sending them out to be agents of change. So how do we do this strategically? In this, since we're going there, we do cover implicit bias, microaggressions training, power dynamics. We also cover core terminology of what they're doing. I'll give a tour on what the experience is. We aren't specifically blame-centric. We aren't specifically trying to do a single concrete step. We want to invoke each participant. This is a faculty development, so clinicians is our target audience. We want them to gain some knowledge, but we're focused on how to have those difficult glitches in implementation. Conversations, system barriers, how do we really navigate those? So you walk out thinking, hmm, maybe I can navigate one more thing to make one more change. Okay. And so just fast forward from 2018, just seed from 2018, we actually became departmentally endorsed, a system endorsed, where we were able to train a majority of leaders within the education system. But then we got adopted during pandemic to do the health system. We got to do individualized customized trainings to the executive leadership, departmental chairs, staff administration. We did customized offerings to 21 of the 26 subspecialties within our health system. Huge honor to do that. So going from seed to aid, seed was a hybrid online class. So you'd do an online module, get your fund of knowledge, a little bit of interaction, come in. Our goal in that one was to do community building too, so four hours of immersion in the content, interactive content with your colleagues. And we did cohort specific, so each department had a custom offering with their group, what are their issues. I would meet with them beforehand and customize the cases that we would cover for that audience. So then with the grant that we received from the American Board of Psychiatry and Neurology, we wanted to develop aid. Aid is an asynchronous course. The question was, could we take what was successful with that 797 to a national audience? Could we make it asynchronous so that people could access it whenever they could? Could we still make it interactive and still get the learning in? That's where the self-assessment comes in. We went from six hours down to two and a half, and we've been accredited through the grant for eight self-assessment ABPN CME credits. And that's really, really something that is a marketing point. So talking about the business of this, that's where we were really, really, really honored. So we have new content, and we changed the content to instead of just working for educational realms, because that's very limited, we generalized it to be for anyone in the healthcare profession. And we tried to embrace that people have different roles and different hats they wear, even within their different roles. So how can we appeal to them doing the change? So we then made it that it's now being currently offered to UC Davis faculty and nationally on the ABPN website. So if you're interested in this course, we did have just full disclosure, there is a recovery cost so that we can maintain CME, because it's not supported in my department. But if you're interested in my course, in our course, it's there on the QR code, and I'll show it again at the end. But we launched the course nationally November 21st of last year. It's had some success nationally and internationally. I'll get into that in just a sec. Can we click on the image, please? Okay. So lastly, I'm going to go to tools and strategies, and it's all y'all, and we'll go to where you want to go. So tools and strategies, please, for $1,000. Okay. So what are tools and strategies that were used in the aid curriculum? How did we get this? What did we get? So what we wanted was to facilitate a thought process for self-development. We also want to facilitate that when harm happens. I have a question for you. Let's pause for a second. I want you to think of a situation where there was a lack of equity or a disparity. You were part of it. You witnessed it. Disparities were the issue. Can you think of one? One scenario. What was the issue in that scenario? I want you to think of that. Okay. Who was harmed? How and what was the problem? And what is needed to make the change? Okay. Y'all have that in your head for your individualized space? I want to ask you something. In your case that you saw, how many of y'all recognized that, or how many of y'all identified yourself as maybe the human in that situation who might have done harm? You don't have to put your hands up, but I just want you to think. It is much easier for us to identify and externalize harm or errors than to embrace that we are human and we make mistakes. This course helps make it easier to navigate that situation. That's pause. And then when you're having a conversation, have any of you had the conversation where you're kind of button heads? Anybody had a conversation like that? It becomes a power struggle. Wrong or right? We've got a rubric to handle that too. And then contrary to regular medicine, oftentimes we don't know how to do an effective apology. In here we go over how to effectively apologize as a provider. It is a skill set that is needed. So these are some just structures that we use. So the strategies we use was interactive. We had resource handouts and we have a self-assessment exercise. Let me just give you the relationship bridge. So this has that there's teacher and learner going over content, but you could just as easily exchange this to be provider, patient, or colleague. If we're giving content to someone else, the content is useless unless it's in a format and relevant to what the person needs. So that's the first concept. Give content that is relevant. The next content is pause, which is when, like I said, when we've done the harm and maybe somebody says, ah, that didn't go so well. And we want to lean into that moment. What do you feel when someone tells you that didn't go so well? What are you feeling? Embarrassed, angry, ashamed. I call that the ugh feeling. Okay. So how do you manage the ugh? We need to give our colleagues and ourselves the tools to manage that. If we're going to have the success, we really need to go there. So with this, this is a rubric on how to manage that. And we have exercises to help the person really manage that and ourselves. The next one is triangulating conflict. I actually had created this to negotiating situations where there may be some personality traits for the primary care world. So when you put an issue between people, it can feel like shots are going across and you're harming the other person. But when you recognize and you can find an ounce of goodness in the other person, if you can't, take a pause, maybe find a different time or find a different way. But if you can find an ounce of goodness in the person, you can actually shift and prioritize that I can solve more issues if I have a good relationship with this person. Maybe they're trying the best they can. Let's push the energy and the issue out. Let's talk about it together. And then maybe we can go through more situations and find a success together, find some common medium. And so this is really, really helpful, especially in our polarized time. And then this is the effective apology borrowed from the wiki, which is a business writing. So if we could click the image, please. All right. So with the small amount of time we have left, if we could prioritize the stars, who would like to have us go somewhere else? What are you wondering? Impact. Okay. Can we have impact? How much would you like to go for that? $20,000. $20,000. Thank you. So what is the impact at the personal level? And I also have national data. I can direct us there. So what do people say after doing this course? They find that they're better able to navigate situations when they're caught off guard. They can interact better with patients, staff, or students. They can also find it helpful in their personal life. Okay. And then here's some testimonials from the SEED education. And then we had integrated it into departments by collaborating with the IDARE leadership. I wish we had time to talk about how we had integrated it into the system. We can get there in just a sec. We had word of mouth, social media. We had national demand. And then I want to share a quote from social media that happened about 10 days ago on the national offering, the asynchronous one. Whoever recommended this course, thank you. I loved it. Great way to fulfill the ABPN self-assessment requirement. I hope something similar is available in the three-year cycle. So I know that people have interest. I know that people want this. And I know that they are finding it helpful. They're telling me. But if we could click on the image, you might be wondering about data. If we could just go to the data, if that's all right. What does the data show? Does this really work in change? Well, we're pretty consistent. When we did our first pilot, we had a decent effect size, and we had educators. Then when we had a larger study continuing with SEED in the systems-wide offering, we were consistent, and we still had the p-values in the pre-post test to be statistically significant. So what integers did we look at? This is fast-forward to 416 individuals. We had improvement in comfort with implicit bias, identifying and defying cultural privilege. I'm capable of providing my colleagues appropriate feedback. I'm also able to describe three methods that I can promote things getting better. These are just a couple highlights. Then this one you've already seen. So then we went to the personal impact. I embedded these to make sure we get to all of them. But if we could click the image and go back. Thank you. Questions? Where would you like to go next? How does it work? Data? I just went to the data. National? Okay. National for how much? 2,000. Wonderful. So we are at the level of national offering, and we went through general SEED offering, which was for all the educators coming through our system as they came on board. They were actually required to do this course. Then we went to departmental customized offerings, and we've also done resident trainings. We've done local and system collaborations, and we've done the national grant and the national offering. This was a $1,000 grant from 2022 to 2024. We created this course. We got accredited with the ABPN for this course. We were able to pilot it with UC Davis folks, and then we're able to expand it to more providers. Well, what did it look like? This. This is 40 days. Forty days. These are the people interested. We've reached Canada, Australia, and India. More than I could ever imagine. We're broaching on 400 individuals who are in psychiatry and neurology interested in this, including states where education like this might not be as permissed. We are excited. Very excited. If you could click on the image. I just wanted to highlight a little bit more on the virtual tour. Would that be okay? Okay. So the online virtual tour, please. Okay. So online virtual tour. I want to show you what it looks like. It's through Articulate. And what we do is we go through. They get a handout with different components, terminology. These are some of the things. I know it looks small. I was just trying to get it on the fewest number of slides. And then we have interactions. They choose their own adventure. What would be their response? And they interact with the module. We also have the self-reflection assignment, which is anonymous. And we have pre-post questionnaires so we can track the progress. And if we could click on the image. I'll just pause there and see if anybody has any other areas you're wondering about. Training collaborations, great, yeah, please. So, what are useful tips when you try to collaborate? This is collaborating with departments, but I also can talk to the trainee collaborations. So when you're trying to collaborate with departments, here's some core tenets, you want leadership buy-in, you wanna get key stakeholders so you're speaking exactly to their truth that they're experiencing. That's why when I was creating this presentation, I'm like, I'm not sure exactly what you need. That's why I was trying to do something where you could pick a little bit more of what you wanna know, because that's when things get incorporated, that's when things matter, and that's what we wanna speak. So, we had departmental chairs and there was also a system sponsorship, but I'm trying to think where I have that slide where the trainee buy-in was. If you could click on the image. Okay. Institutional and local, please. Okay, so this is where I'm able to get into it. Here's the residence, okay, thank you for your patience. When it comes to the residence, we trained OB-GYN residents as part of the departmental offering, but then in psychiatry, the residency program adopted it for PGY-4s. The PGY-4s said, oh, I wish I had this earlier in my training, so then we did it to PGY-1s. Then it's now become an annual offering within peds and psychiatry, and it's really a joy to do that. We're working on integrating so it's actually offered in intern training for all departments, because we know that this information is helpful. The key is don't do it without checking in with the people who need it. If you're not grounded to those needs, you can't always help, including those who may be making missteps, right? When people are making missteps, it's easy to other them. It's really easy to have a lot of feelings, but they can be these agents of change, too, if we can bring them along. I want you to just, as closing, I want you to just think of when you made a mistake. What helped you get through that? What helped you? Support? In what way? Yeah, the humanness, bringing back the humanness to medicine. That is how we're gonna be effective with mental health disparities, and that is how we are gonna be effective addressing equity is bringing back the humanness to care. So click on the image, please, and then the arrow at the bottom. Great, so just remember that while we are taking on a large undertaking and you're here for a big project, small changes can have big impact. This course started off really small, and now we're national, and I gotta figure out what's next. I am conscious of people who may not want it to be national, so I'm trying to work on how to keep it preserved within the ABPN, but believing you can make a change and allowing others to help make it habit for incorporating these interviews is gonna really be the difference, so thank you again to my team, thank you to you, and thanks for your time. Okay. Dr. Argyle, if you can join us. Okay, so we're gonna take a few questions. Feel free to walk up to the mic in the aisle. Hi, Dr. Argyle, I have a question for you. So, circling back to your excellent presentation and the implementation of the CFI, it is important to think that there are different ways of seeing and knowing, but given that you invoked the C word of capitalism, which I live in as a department chair, and the pressures to implement within structures that aren't sustainably funded, what might be, from your research and experience, the most high-yield questions on the CFI? And if you refuse to winnow it down, that's okay too, but I'm curious, because when we think about constructs and scales, we always try to have brief versions of them, and I'm wondering which of the questions might be some of the most impactful. Thanks. Oh, I have a microphone. First thing, please call me Neil. Dr. Argyle is who I am whenever I'm in office. Second question is, I'd like to respectfully challenge the tenets of the question itself. I don't think we should necessarily assent to the fact that we belong to a market medicine enterprise, right? I think we should be asking a different question, which is, how do we provide good care despite the fact that we belong in a capitalist, for-profit medical enterprise, rather than assenting to it? Because I can show you, from the work that I did, if you Google pharmaceuticalization and care coordination, and outpatient mental health care, and my last name, that because of the way CMS funds quality measures, that more and more institutions now are making medication management and the need to see two different providers, typically a prescriber and non-prescriber, the default pathway, right? When a person comes in and tells you, I just want psychotherapy, and yet they don't want medication management, they still have to see two or more providers, we should then start to ask ourselves, what is the system in which we are embedded doing in terms of increasing costs, whether it's transportation, or time off work, or other kinds of indirect costs to the folks who are coming here and letting us know what they want in terms of treatment preferences, but the system itself doesn't allow for that to happen. So when I published that paper, I started to realize, well, going back to Bhuja's really wonderful diagram of the individual versus interpersonal versus institutional concentric circles, that providers can only do so much based on the political incomity in which they're embedded. So we can offer so much amazing evidence about how providers should ask this question versus that, but if providers are eliciting treatment preferences and social determinants, but the institutions in which they work actually entrench rather than overcome what patients are telling them, when clinicians are willing to answer those questions, then it's not gonna work. So my second kind of answer to this would be to say, well, I think we should all find ways of making sure that medicine doesn't get subsumed to just political economy and all of the individual capacities that we have in our work. To answer your question in a way that I think you wanted me to answer, I would say the easy way to think about it is what is the kind of information you're trying to get at this particular point in time if you can't do all 16 questions? If you're trying to understand intersectional needs, then questions eight, nine, and 10 around identity would be helpful. If you're trying to understand questions around social determinants of health, then questions on social supports and stressors would be helpful, or barriers to care. If you're trying to understand current treatment preferences then questions 14 and 15 and 16. If you're trying to understand how what someone thinks would relate to what their treatment preferences would be in terms of causes, then questions four and five. Hi, I do have a question for you, Neil. Have you considered also in the age bracket of maybe 35 to 55 in the women's health for menopause? They do say that hormones do affect depression, anxiety, and stuff like that, and that a lot of the doctors, instead of saying, oh, let's check your hormones, that they will just give you a SSRI right away. Would you consider adding those kind of questions, saying, hey, do you feel that you are in, what are your other symptoms that can carry into perimenopause, and how would those things affect your mental state? So this is a great question, and it shows, I wanna reframe your question in slightly a different way, which is that the challenge in creating supplementary modules for different populations is that we see that different, like basically different populations that are not 18 to 44 that are typically male and that are typically of European ancestry get othered. So children and adolescents fall in that age group, elder folks fall into that age group. And so our challenge in trying to develop questions or supplementary modules for the CFI is how do we provide enough cross-cultural information or domains of assessment that all providers would be able to ask across different populations while asking questions that might be unique to certain populations? Unfortunately, in our published scholarship, we don't have anybody who's looking at the connection between women's physical health and women's mental health. That's a huge gap, and we need more work. So I invite you and anybody in this room who wants to participate in that, and I can tell you I'm on the editorial board of cultural medicine and psychiatry, of trans-cultural psychiatry. I'll help you get your work published. We just don't have that data. But we also know that those cultural needs need to be assessed and addressed. The goal, I think, in doing a CFI or any kind of cultural formulation to see is to really wed certain kinds of assessments, but to make that the start of a conversation, not the ending of one, right? Because somebody's going to be getting social and cultural information, but if you're a provider, you're also trained in a biomedical framework as well. So we're trying to encourage people to embed symptoms in that social and cultural information rather than abstract it and assume that just people are walking beings of physiology, divorced from any kind of sociocultural reality. So we don't want people to stop at just the CFI, either for their own cultural development and skills or for not needing to do the rest of a biological assessment. We're just trying to supplement it in that way. Hi, my name is Mavishek. I'm a local psychiatrist from Maryland. Thanks so much for the wonderful presentation, very thought-provoking. This is a common question and maybe just a future idea. So these questions are wonderful, they are great, but I think we need to kind of train our, especially incoming generations of doctors to incorporate these more. So I can literally think of, under history of present illness, you can ask like one, two, and three, right? So I think if all of us kind of get worried that, oh my gosh, one more thing to do. And so my personal style of practice is like, I try to keep it at least 20 minutes for like the open-ended conversation. I want to hear what this patient came in for. And sometimes I realize at the end, oh my gosh, I didn't go through like DigFast or CiggyCabs or something. But by that time, I have the idea of them as a person. And that gives me, I think, much more better diagnostic ability, right? So if we train ourselves and our incoming generations of doctors, just to formulate these questions within the part of like the typical HNP, we all have been taught all from since we were born, I think, as doctors, right? Rather than having that as a separate 20 minutes things to do, like under social history, like why wouldn't you ask them, who do they count as their support system? Like, why wouldn't you ask them that if they're stressed, who did they reach out to? Is faith important to them? Like all these questions are literally part of that framework. We just need to be a little bit more mindful and move away from like, just like the tabulation of symptoms. Just the thought and probably less stressful way of adding another thing to do kind of, you know, so. I wish you were running SAMHSA and NIMH. Can I add that I was just thinking about my county work at Sacramento. And one of the beautiful things is our clinicians do an annual assessment for our patients and they have a culturally embedded interview. And that's normalized. That is the standard. That is how we interview and it's embedded throughout. And I think more counties that have it, more spaces that have it, the more successful we can be. Thank you so much for this module this morning. I really appreciate the revised interview I plan on printing a copy and keeping it in my office. I've tried to work pretty hard at being culturally mindful to bring cultural humility in my work in a diverse community. And I find that, you know, hooray, I've gotten there. I think in the eyes of many of my patients, it seems. But it takes, I find that it's taking me into new frontiers. So for example, just yesterday, I was speaking with a patient of mine who is a survivor of self-described medical trauma about a chronic medical condition. And she was appreciating how sensitive I am to her trauma. She said I'm the only clinician she's ever described herself as having experienced that. On the other hand, I am personally very concerned about chronic benzodiazepine use, given its correlation with earlier onsets of dementia. For her, who has a chronic anxiety condition, culturally sensitive psychiatry for her is my continuing to prescribe daily clonazepam. And I'm just kind of curious, how far does humility take us? How far is it paternalistic of me to impose my concern about dementia to someone who says, you know, you can't know what it's like to live as I do? I have negotiated a kind of a compromise where she has some drug holidays to avoid tolerance. But I feel I'm in the right place with it, but I feel it's taken me into a difficult place. And it seems to me this might be perhaps part of the pushback against too much humility. Do we lose our role as an advocate for our patient's well-being? Do you wanna go or do you want me to go? You go first. So I, as I mentioned before, the social science that I tend to gravitate most to or that I'm trained in is medical anthropology. And so if you look at the cultural formulation interview and then the scholarship that it's based on is, it comes from this fundamental distinction between what the clinician's biomedical understanding of diseases and what the patient's like understanding of illnesses. And so this idea of translating between a person's inner experience and how that ends up becoming codified or professionalized in a healthcare context is what has captivated two generations, now three of medical anthropologists in the communities I work with on that side of the campus, you know, in the Department of Social Sciences at Columbia. And the idea has been for much of our kind of work in culture and specifically within the American Psychiatric Association that as long as clinicians align themselves and align their model of disease with patient models of illness, then like we can reach the finish line, right? There'll be successes. I've been more interested lately in like forensic contexts where fundamentally patients experience forms of distress or illness that are fundamentally misaligned with clinician understandings of disease. I'll give you an example. How many people here have worked in an emergency room? How many people here have seen people brought against their will? Right, most of us, right? So if you ask question one in the CFI, what brings you home here today? What's the answer you're gonna get? The police, bingo. Do you think they wanna be there? Absolutely not, right? So in those settings of mismatch where the clinician has to do some work and patients don't wanna be there or anybody ever see folks with diagnoses of personality disorders that do not wanna be in your clinic or substance use and do not wanna be in your care, what's the best that you can do? I still think that there is a role for some of the questions that we ask about. Like, I know you don't wanna be here. We've tried implementing the CFI in a forensic, like a high, highly, in a forensic context where there is high criminality and repeat folks who go through the criminal justice system because as I mentioned to you, I'm pretty public about my involvement in the criminal justice system and I think a lot of folks who tend to look like me or darker don't wanna talk about it so we're never gonna address this problem unless we get more of an evidence base around it and even for folks who disagree with their clinicians, having a space to talk about those disagreements with active attempts to search for collaborative solutions I think is a way that advances the conversation that recognizes the realities of how people are structured socially in a clinical encounter without necessarily attributing it all to the clinician's lack of understanding or the patient not being acculturated enough in society as to like ascend to what the clinician wants them to do and then documenting all of that and sharing that information as necessary so that way you can like incrementally, even maybe asymptotically move the conversation forward is still an advance from like minute zero when that person first walked in and you didn't know what that person was thinking and that person knew what you were thinking. So I'm very clear-minded that there are sometimes limits to what we can do and there are clear structural realities like the police or attorneys or like in New York we have ACS or DCF, right, the Administration for Children's Services or Department of Children and Families will impose structural constraints but then as long as you are willing to have those conversations, I think you're able to elicit information that might be somewhat able to build rapport. And just to add to that, you can use one of the tools to negotiate the conversation. It's a meeting of experts in the room with your patient being the expert on their life and you having some medical expertise. And so you made me think of one of my patients in the county setting. She has horrific trauma and one way she found the best way to get through that trauma was by purchasing opiates and numbing because she couldn't address it but then we were also giving prescriptions of benzodiazepines. So obviously there's a life threat but I could also see the person there doing the best they could. So we literally triangulated the conflict. I'm like, okay, I'm gonna do this. I'm gonna have the model. I'm like, yes, so what I gotta do is I need you to have no respiratory depression. I just need you alive and you're the expert on this. I was like, this is gonna work. She got up and walked away. I was like, oh no. She called me back a couple of days, actually later that day. And she goes, you know, it was just too much in that moment but I see what you're saying. Then we were able to negotiate and find a common ground. She was able to get on buprenorphine so she didn't have to seek and purchase which was less of a financial burden for her but she still got treated. Then she was able to actually stay within the realms of the benzodiazepine dosing. Then she was able to move on with her life, get a job where she could sustain herself, have healthier relationships. And she actually graduated out of our clinic because she was able to get the job that had associated insurance and she had more inclusive care for her medical issues. And while it seems long-winded and perhaps one-off, I've actually had more than that. So I think the answer is it's tricky but have that conversation and see them, share the power. See them as the expert on their lives and you can bring your expertise and find that realm. Thanks for your answers. Any additional questions for our panelists? All right, well, let's give them both a round of applause. Thank you, Dr. Argo and Dr. Chavez. Thank you so much. All right, we're going to take a quick five-minute break, use the restroom, refresh your coffee, grab a couple of snacks, and then we're going to jump right into the next session. So five minutes.

cultural disparities

psychiatry

cultural sensitivity

mental health care

Cultural Formulation Interview

sociocultural factors

person-centered healthcare

equitable healthcare

Advancing Inclusivity and Diversity

cultural humility

inclusive healthcare

patient trust

treatment compliance