Thank you, everybody. Welcome to today's session, Navigating Leadership in Residency, Trial by Fire. And we're pleased to have this resident and fellow-led panel of presenters who have taken the initiative to organize this, to work on the content, and obviously are going to be delivering the content here today. We're very excited about the details of this presentation. The objectives, as you can see, include how assessing residency training structures addresses DEI. We'll be addressing how to identify intrinsic biases and how they can affect the distinct psychiatric workforce and demonstrate how a chief resident leadership training may help enhance and improve and grow diversity, equity, inclusion, and belonging. None of the speakers have any relevant financial disclosures. The cases are based on real-life scenario. But obviously, the names and the individuals have been de-identified to ensure the privacy of the individuals and the institutions. And a special shout-out and thanks to Dr. Lamelo de Faria from the University of Florida, who was really a catalyst in also making this happen as well. So without further ado, we're going to turn it over to Dr. de Graff. Good morning. Thank you for the introduction. Very kind of you. You mentioned Dr. de Faria. So how did it start? How did this group get together and put a project like this? So everything started with a ripple effect. So what is ripple, right? So the Florida Psychiatric Society, which is a branch of the APA, put together a mentorship program where they invited chief residents to be, or newly named chief residents, to a leadership training program. And we were able to meet different mentors, interact with peers, and exchange ideas. And it was a thanking tank, an incubator, where a project like this took place. And thankfully, Dr. de Faria was, like you mentioned, a catalyst and a mentor and a good inspiration for us. So we ended up talking about DEI. We got interested in the diversity that we think should be a primary point in medical education. And we started working right away. So we're talking about graduate medical education. We have to mention ACGME and what is their stand on DEI. And they add belonging, which is sometimes missing as well. So the ACGME Department of Diversity, Equity, and Inclusion, they provide knowledge tools to the GME programs in the community to advance physician workforce diversity and build a safe, inclusive, and equitable environment. So how do they do that? What are the keys to that objective? So they focus on education, obviously, outreach, which is what we're doing right now, outreach programs, research to make sure that the data is out there. They focus a lot on recruitment and sensing how we're doing around the country and different programs in the country, and also accreditation. They have rules and regulation that programs have to adhere to and make sure that the goal is going how it's supposed to be. Obviously, those rules and guidelines affect different stakeholders. Residency program and institution alike or in partnership must engage in practices that focus on systematic recruitment of underrepresented minorities. And there has to be an evaluation, an evaluation, if you like, that must include assessment of those projects, of those goals, and how you attend them. It should have the process of education of residents, faculty alike, and to coach about behavioral engagement in the hospital, in the workplace. Residents and patients, as well, take part of that objective. Residents should have training in competency, cultural competency, being comfortable with the diversities in the communities, being sensitive to cultural differences and religious differences, gender, racial, ethnicity, and different beliefs. And patient, the institution has to be able to provide a wide diversity of patient to the training program so they can be trained in cultural competency. Now, we have the objectives, right? We have the goals, but what is making it so difficult for institutions and programs to accomplish this goal? So we all have biases, but our interest today is to define what's the difference between implicit and explicit biases. Obviously, we know that implicit biases are unconscious, contrary to explicit biases. We have them. They are innate to all human beings, and one is generally unaware of these biases, right? It affects the way we interact with others, but we're not aware of them. It is imperative, then, to know what they are and to be able to acknowledge them, to label them, and to take action before they actually comment on our decision making. We need to be able to understand that we have blind spots and make a stop before we take snap decisions and be self-analytical. But for that to happen, we have to understand how does it happen that we have implicit biases? How does a human being have snap decision and unaware of their biases? So we know that over time, our brain uses our unconscious memories, cultural background, life experiences, to triage an infinite amount of information that we receive, right? You know, in every situation, this amalgam, this conjunction of experiences and memories will lead our decision making abilities. How does that become a barrier to the challenge or to the goal of having a diverse, equitable, and inclusive workplace? If you're striving towards DEI, we know that those barriers can, let's say, can affect the hiring processes, affect the underrepresented minorities, right? If we don't know that we have a certain bias towards that group of people, that group of ethnicity, or that group of gender, then our goal would be hindered in being able to achieve it. I also need to mention that it's one thing to recruit minorities, but also very important to make sure that they have upward mobility, they belong, right? They belong and they have the support they need to succeed. It's not only recruiting, but also retention of minorities and providers. Now, mentioning those biases, there's a few of them that are not necessarily more common, but more identifiable. We all are comfortable, or we all should be knowledgeable in what gender and specialties or gender or profession biases could be, right? I'll give an example. When we see patients in our office and they mention this here therapist, I would be the first to say my first instinct is thinking of that therapist as a woman, and I'll be she, I'll say, I mentioned as a woman. But the statistics shows that it's about 65% female and 35% male psychologists or therapists in the country. So that's an implicit bias. I assume that it was a woman. Likewise, in patient services, you could have a male provider and a female provider walk into the room dressed with the same cloth, with the same scrubs, and the patient might believe or might think that the nurse should be female, although the attending should be male, whereas it could be different. We'd have an attending female and a nurse male. So those are different biases that we all have and that we have to be conscious of. Fortunately, psychiatry residency programs have been in the forefront of leading diversity in recruitment in residency program. We do have, among all the programs in the country, the most diverse, I'd say, recruitment in residence, per se. However, we do not necessarily see that diversity when it comes to recruitment and retention of faculty and attendings in hospitals. It's one thing to have a diverse residency program, but if it doesn't translate to the workforce as far as attending and faculty, then there's a problem. We can appreciate this graph here of the US psychiatry workforce, and you can see very clearly that 64%, more than a half, is white Caucasian, and we have some Asian, and if I go all the way down, you see Native Americans and Black American. So that is an issue with retention of minority after training. I mentioned the type of biases that could be the most identifiable, meaning gender, race, or whatnot, but there's also very common biases, and these are biases that we're not privy to, right? Affinity bias is when one feel, one have a preference towards someone because they share the same values, or they have the same belief, and then they could possibly play favoritism when compared to other coworkers or staff. Hollow effect is when we are clouded by the one good quality of someone, and we are being fairly good judges of characters, ignoring the bad qualities or the shortcoming of the staff or coworker, and in the opposite way, the Horn's effect is when we are too aware of one negative effect of someone, and we're not able to see the good qualities, and our judgment is impaired, is clouded, because we focus on the negative quality of that person. So being aware of those implicit biases before we take decisions in leadership or in training is very important. Now, how did Ripple, or how does Ripple, the leadership program, help residents change that dynamic or change the course of graduate medical education for the future? So I like to say that chief residents are a baby attending, they're baby faculty, right? We are the nexus between faculty and residents. We are the closest thing to the residents and the closest thing to the attendings, and being able to understand those nuances of cultural nuances in training and being able to train our junior residents in being sensitive and in training each other is very important. Our role is to provide guidance, is to shift the program, to change the cultures, and to leave it the way, a better way that we found it. Chief residents should have a position of, it's a privileged position where you can leave your mark. And we're talking about DEI, as chief resident, I could share that we have had circumstances where we are challenged by our biases, right? And the three challenges that we can see is that creating that culture, right, we have to be very clear with expectations. We cannot take the decisions with our residents without them knowing the reason for the decision-making, right? We have to be clear, we have to be a clear goal and define them very well. And also, we have to align our objective with the community, with institutions, making sure that everybody's on the same page so we can get supported, right? So, to finalize, I think our experience was worthwhile, and I think that we've learned, I'm fully confident that we've learned that to be a good leader, it's not necessarily looking at the result or the production, but also looking at the processes and who gets involved in that process, right? If it's a good result, we're gonna make sure that everybody was included, there was an inclusive process, making sure that that result is generated by everybody chipping in, right? Everybody feel that belong. And to have a good illustration of what we've encountered in terms of difficulty in leadership and DEI, we are going to discuss some cases that we've encountered, all three, and hopefully it will be a discussion and we can learn from this. I'll let my colleague, Dr. Zakaria, continue. Thank you. Thank you. Just a space bar? Right. Okay. Thank you for the introduction, Dr. DeGraff. So, this portion is meant to be a little bit more interactive. We're gonna set up some different scenarios that each of us has gone through over the last year as being chief. I'm currently chief fellow of the Child Adolescent Psychiatry Program at Citrus Health in Hialeah. And this was one of the issues that I experienced during my time. So, just to set up the demographic of the incoming CAP1 class, Child and Adolescent Psychiatry class, there were six fellows. Everyone was bilingual in Spanish and English. Four males, two females. Of the males, two were married, two were single. Three had kids, one didn't have kids. And of the females, one's married, one's single. One has kids, one without kids. So, pretty good, pretty diverse there. Now, to go into my own background, I am Indian. I am not fluent in Spanish. So, a little bit different there. I have been married for five years and I have three kids. So, that's my background, just to share the differences there. So, the first month as chief fellow, we started having inpatient calls. It wasn't something that I had my first year as a fellow. It was something that was just started. So, on top of being able, on top of being the one to kind of introduce that to the new fellows, we ran into a situation where the very first weekend of the weekend calls, that first month, one of the CAP fellows called out. She attended the call on Saturday, but then on Sunday, she messaged the attending, who was a male, that weekend. And the attending kind of inquired as to the reasoning behind why she wasn't able to make it. And as a new fellow, not really sure how to handle things, what to say, might have over-divulged a lot of personal information to the attending that she has a newborn, her partner was sick, so she had to be with her baby, who was sick, vomiting all night, and was very tired and wasn't able to, didn't feel like she was able to drive into the call and that she just couldn't handle it that day. And so, she needed to take a sick day. I got texts after she already had this conversation with the attending and then I also started getting messages from the attending about what's going on and then what is the, what happens next? Because this was the first time that we were doing calls, there was no precedent of having any sort of backup call system. So, I contacted my PD. Since there wasn't anything in place already, we just had to excuse the situation and then try to rectify what we were gonna do about it. And in doing so, the attending wrote an email to me, the program director coordinator, regarding the situation and why he felt that the reasoning for the calling out being inappropriate in his view. So, what happened next is that I debriefed initially with the fellow alone, tried to get a perspective of what was going on, how we could support her, and then also the CAP1 fellows all as a group. And I discussed the need for a backup system and some policies on when it's appropriate to call out, when it's not, how can we mitigate burnout, things like that. And from my perspective, it seemed logical to have a backup system in place. And I guess I did not expect this to become an issue of sexism. So, in speaking with the different fellows, I asked for ideas on what they thought would be fair. And what I received back was that the females thought that it should be very equal. You miss one day, you make up one day for the next month, for whoever had to take your place. But then the males brought up a different idea and said that, well, to kind of motivate you not to call out, one missed day should mean that you do two, like a full weekend for that person the following month, which kind of surprised me because I hadn't thought of that. And some of the other comments that I received from the male side was that because they're moms and moms are more likely to call out because of their kids. Another perspective from the male side was that we don't need a backup system because we'll never call out. And then that the female should cover each other and then us males will cover each other. So I didn't really expect it to turn into this kind of male's female situation and was kind of surprised that this is the feedback that I was getting and how to go about managing this. So I had to take a step back and kind of think about what are my own biases in this situation? I'm a female, I'm married, I have kids, I know that I've had to call out before because my kids have been sick. And so these are just some questions that just to help start the conversation. But I would love to hear if anybody else has any ideas of what they would do in this situation. Was there any, do any of your own gender biases come up when you hear this situation? From anybody? And speaking of the mic, I think we have questions that are being recorded. I know I'm not supposed to because I'm the chair, but I'll start it off, right? Because actually, ACGME allows this under the policies that it stays silent, extended leave more than two weeks, which is called extended leave. They said you're not supposed to require to make up, but under two weeks, they're silent, right, from an accreditation. So it becomes a program-specific question. But based on the foundational, what are the foundational values you have achieved individually or the programs, right? And one of them I would bring up is fairness, right? What is fair, right, and what is appropriate as opposed to what I think or you think, et cetera, right? So one of it is driven by the program and the individual's core foundational values like fairness, right, so. That's not a specific answer, right? I'm just gonna say that we need to have to get to a specific range of achievement. I don't have a question or an answer, but I'll just make a comment. We have female in my program. They've been pregnant during the program, and the general sense was that we appreciate them working while they're pregnant. So I think seeing it differently, I would say having female coworkers in the workforce and still see them working actually raised the value more in my eyes than me otherwise. So I don't think that women should be, quote unquote, paying for being pregnant and being vilified. I think they should be celebrated. So that's just a comment. Thank you. And that was one of my other questions that I was thinking of is that I know that I've had to take maternity leave, and my co-residents or co-fellows have had to step in during that time. And so from a male perspective, it would be interesting to see how maternity, paternity leave affects the rest of the training program. I don't know if you guys have any perspectives from the other side. In my program, for example, we have about six females who have gone on maternity leave while in residency. One of them has gone on maternity leave twice during her training period. And we've had three men go on paternity leave. Sadly, our hospital policy for paternity leave is two weeks, but it is what it is. For maternity leave, we usually allow two to three months, depending on the residence. It doesn't really affect the way we do our coverage schedule. We are, very thankfully, a very large program, and so we're able to redistribute the work amongst ourselves, but you do feel it sometimes when you're doing some of the on-call shifts, you feel a little bit alone. We don't really ask our own residents to make up that time that they spent. We work on a very personal, you-to-you basis, so if one of my colleagues, she went on maternity leave the last two months of our intern year, so I had to run all the weekend shifts by myself, and I didn't really view it as a thing of like, oh, when you come back, you have to cover half the weekend shifts or all my weekend shifts. It was more of like, hey, I'm glad, bring your baby when she's good, and well, every time that when you come back, she will have to, it was over two weeks of extended leave, so she will make up that rotation at some other point, but it's more of a, I know if tomorrow I were to break my leg and fall sick, I know we have a good personal relationship within the program fostering that, so I know my classmates and anybody else in upper levels or lower levels would cover for me if something were to happen. I have a question. Hopefully somebody in the audience would venture in and serve, because I know maybe some of you may have experience in leading medical programs, GME programs. As a leader, maybe a program director or chairman, how would one of you would chip in in that situation, saying what's right and what's wrong and taking a decision that this is how we're gonna do it and not let the chief resident deal with it on her own, having the support that she deserves? Well, I'm Dr. Eugenio Roth from Miami. I can tell you that 30 some years ago when I was chief resident, we had to meet with the chairman of the department who, I guess the residents elected the chief resident, but the chairman had to bless it, and I remember the chairman said to me, we appreciate that it's a popular vote because you have to be very popular because your popularity is gonna start declining the minute you become chief resident. So by the end of your chief resident year, you're not gonna be popular at all. And the point being is that you're gonna have to make a lot of decisions where people are gonna be angry at you, but you just try to do the best you can and you try to be fair and inevitably, somebody's gonna be unhappy with the decision, but you have to trust your judgment that you're doing the best and the most fair, choosing the most fair alternative, but there's always gonna be somebody unhappy about it. Thank you. Thank you. Does anybody else have any thoughts on the case or any examples of gender biases that they've faced? That was your conflict resolution skills, right? So what ended up happening is that I, after meeting with everyone together and then after a lot of people met individually with me as well to give their two cents, but I decided that it would be a one-to-one. You miss one day, you make up one day, keep it even. And we came up with a backup system plan. We did have other hiccups along the way, but ultimately it's been working out so far. So that's what we ended up doing. Did you think the support of your program director leadership helped solidify that, I guess, decision? Absolutely, yeah. After I spoke with everyone, I presented that to the PD and the PD was 100% supportive and on board with that. I think that's important. I think being a good chief, a good leader is good, but if you don't have the support, it's almost like you're on your own. And I think in my experience, being supported by my program director gave me a lot of confidence in taking the tough decisions because I know I would be supported, but I think that's very important. Yes. If you don't want to scream. Thank you. Yeah, I just want to say, this is such an interesting case example, and I just want to compliment you on, first of all, that you created such a level of psychological safety that people were willing to actually share their attitudes. So even though it's kind of jarring, I have to admit, as a mother and a woman, I was like, oh my gosh. It was probably a sign that you had created a culture where the male trainees felt like they could say how they really felt, the women said what they really felt, and then you made an important decision. So I really like that. The other thing I would just suggest, as you were commenting on in terms of your culture, I really think that having very explicit discussions about how there will be moments we don't know where your parent might be ill, or you might be ill or injured, or you might need to take time off for mental health reasons, or your partner having difficulty. And so we look out for each other. We are a family, a community. We look out for each other. And often, I'm a psychologist. I work with residents and faculty providing counseling. They're terrified to take time off because they don't want to burden their team. And so talking with them about how many times have you covered for other people? They'll cover for you, and you'll look out for them in the future. And the other point I would make, too, is I think it's an opportunity to educate the attendings about the way they respond, like how do they handle these situations? What kind of follow-up questions should they ask? What should they not ask? Because I think that's where part of the problem is. If the attendings are kind of acting all fussy and being judgmental, the residents or fellows pick up on that. So I would have the program director or the chair also work with the attendings and you as well. So, but nice work. That's a great conclusion. Thank you for sharing. And yes, that was the other part of that, is that the program director took it on himself to work with the attending. And yeah, anything can happen. That was one of my arguments to the group that you never know what's going to happen. And interestingly enough, one male came down with COVID and had to call out of a call. And one male ended up getting stuck with a delayed flight and had to call out. So lessons to be learned. Now I'm going to turn it over to Dr. Jose Haya, who's going to present the next case. Thank you. Good morning, everyone. I'm Dr. Jose Haya. I am a PGY3 Associate Chief Resident at Larkin Community Hospital. So I'm going to present my case now. It's about trying to integrate the opinions of the LGBTQIA2S community within our program and some of the hiccups that we had at the beginning. So just to kind of give you a brief background, I was elected Chief Resident, Associate Chief Resident last year. We are located primarily in a minority-based area of South Florida. We are one of the largest programs in the nation. We're over 52 residents, primarily Hispanics, but we have people from all around the world, India, Pakistan, China. We joke that we're only missing an Australian in our, because we have an Australian and a penguin, because we have basically every other continent represented within our community. It's a very diverse type group. But as I mentioned in my previous comment, we, even though it's a huge program, we all end up feeling very much like it's a family. We really do have that beautiful culture in my program. So this was a case that happened at the technically beginning of the last academic year, but it kind of bled on through. We had an intern who was lagging behind in their clinical progress and their clinical activities or knowledge. They were not being able to meet up standards such as the time that it takes to create a patient interview, develop a plan. He was having other conflicts with other residents regarding tardiness to sign out, missing calls, et cetera. Eventually, the resident was placed in remediation per our hospital protocol. And after failure to meet with those remediation goals and various meetings, the resident was placed on administrative leave and then subsequently terminated. He, throughout the process, had few issues regarding, you know, disregard for some safety protocols, disregard towards other people. It became a big issue within our program, sadly. So during the events, I approached the resident as a senior within the program and I offered to help them. They were not that receptive to my approach. I wrote this case as more as a, I want people to get in the mindset of what happens if you're actually going through the motion. So if you approach a resident and what happens if they're not to open to, you know, being, I tried to be very communicative towards them, very like, you know, hey man, what's up? Like, what can we do? How can I help you? What's going on? Like, do you need help in how to write your notes? I can give you a template. During remediation, the resident alleged that he was being looked down upon, bullied and discriminated against based on their sexual orientation. Basically, he stated, they stated that they were receiving more work and more violent patients than the rest of the residents were because the program had a culture of discrimination and alienation towards the community. The resident referred that their attitudes directly resulted from the culture within the program and then accused me personally and other people of perpetuating the culture of discrimination, just, I forgot the word, I know it in Spanish, but basically just pursuing him relentlessly, just trying to get him to quit. So after the resident was terminated, a formal complaint letter and lawsuit was received from the resident stating that he had been terminated due to discrimination on their sexual orientation. The resident alleged that they were targeted and held back in the program due to their personality and due to other things that had happened. He stated various episodes of targeted bullying on behalf of residents, staff, faculty, and patients, and he accompanied this letter and the lawsuit with videos. The person got into the point where they were, they managed to get inside the security cameras of the hospital, completely illegal behavior, and he found videos of him, of patients attacking him and other people saying, the way the videos were framed had no audio, so they all looked like he was being attacked. This obviously created an outrage. It was a whole issue. We had protests outside the hospitals for weeks. It was a whole thing. The community even posted, the LGBTQIA2S plus community, posted a notice to not attend our hospital, and it was a big issue. Eventually, when reviewing the footage from the actual security cameras, we saw that the resident was actually targeting patients, taking them to other areas, and then basically harassing them to the point where the patients became violent with him. It was a big case. So throughout the process, before eventually this came to light, when they accused me, I felt very, I felt hurt. I tried to incorporate into my program a family sense, a vision of we're all together in this, regardless of race, ethnicity, culture of origin, what you identify as. My program is very inclusive. We all love each other like a family. We'd all cover for each other if somebody was pregnant, dying. And it really, it hurt me from a perspective, and it really, it freaked me out in the sense that I thought, am I really being discriminatory against the LGBTQIA2S plus community? Am I really guilty of, am I giving them more workload, or do I feel like I'm giving them less workload then because I feel that I'm doing something to hurt them? Am I alleviating, am I fearful of retribution from the community because I might do something that might offend them and then I'm scared that they're gonna do a protest in front of my hospital or my clinic? Am I afraid that I'm doing something to put them further on edge, or am I giving them special treatment? Where am I within? So these self-reflection questions are also meant for the audience, and if anyone at this time would like to share or if they've ever experienced anything like this. I think you're saying that you felt like you're overcompensating or trying to undo what they might have thought that you were doing, possibly not being fair to the other residents? For my case, I felt like maybe I wasn't being fair to that resident or other residents. But in the end, it's a question you have to ask yourself and see kind of where you feel you're at. Well, Ian, it sounds to me like a typical case of projective identification, where you have an individual who has a lot of feelings and somehow you get hooked into the individual's feelings and you start feeling accused and pulled in. Going back to my previous comment about the popularity of the chief resident, I think one of the hardest things and one of the most valuable experiences of having the opportunity to be a chief resident is to learn that even though you think you're doing the right thing, you try to do the right thing, somebody will be dissatisfied and that you have to hold. It's very similar to when patients get angry at you and you know deep down that what you're doing is probably the most therapeutic thing, but you have to hold in the anger and contain the anger. So as a chief resident, I think part of your job is to be a container of affects of the entire resident group and also the mediator between the interests of the attendings and the staff and the interests of the residents. So you have to be a negotiator and many times you're gonna feel very off balance and very attacked like you're not doing the right thing and I think that's part of the, when you look at your countertransference, you start feeling attacked and then you have to analyze that and say, well, what's happening with the other person and what's happening between the two of you, et cetera. Thank you. Does anyone else? So to kind of share on the conflict resolution, what we decided to do as a program was we established within our own, I mean, we're 52 residents, so we established a committee for the LGBTQIA2S plus residents. They basically started their own group as a subdivision of the DEI community that we had within the hospital and they've actually put forth a few statements regarding of whether they feel treated equally or not and basically kind of what they do expect as equal treatment and what is not expected and we're now currently incorporating those into hospital policy so that we can go through those motions of are we being fair, are we not being fair, what is too much workload, what is too little workload, is there any special consideration that we need to take because of this? Do we have a patient who specifically has something against the community and are we putting you in harm's way because of that or are we excluding you completely from your training because we're like, oh, you can't see patients because this is happening and we've had so far very successful results, not without its hiccups, without its road bumps, but I like to think it's the road and you have to have fun as you go through, but anyway, thank you. I will now lead you on to back to Dr. DeGraff with his case. Thank you, doctor. Hello again. I'm Dr. DeGraff. I'm from Mount Sinai in Miami, in South Miami Beach. I'm a fourth year chief resident and I will go through my experience, the most, I guess, memorable experience I have had as a chief resident. So we talked about gender, we talked about ethnicity, we talked about sexual orientation, but what about ageism, right? We kinda don't really see that being discussed in workplace and more so in residency where everybody seems to be in the same age group. So this is gonna make up my program, right? We're keeping the theme of diversity, equity and inclusion in mind, right? And I guess we all can appreciate that this program seems fairly diverse, right? It's a Latin rich area in Miami. The faculties are as well distributed as a residence in terms of genders and also in terms of social identity, right? So I think I would, I guess everybody would agree that we try, at least the program try to be as diverse as possible. So here you can see the makeup of the diversity of the program reflecting in the community. Obviously, it's a Latin community and the faculty and residents would probably reflect the community they serve, right? We even have an Indian resident, we have a European Jewish resident and some African-American and African-Caribbean resident. So here's where the work starts, right? This is obviously my experience, but I would love for you to actually put yourself in my shoes and see how would you feel, how would you deal with that experience. So it's June, last week of June, and you were named chief resident, right? It's great responsibility. I think Dr. Roth mentioned that you want to be popular and you probably end up being less popular at the end. But that's what you're crowned with, right? So here's the dilemma. Charles, right? He's an African-American resident. He's a 47 year old male. He grew up in the South. I believe it was somewhere in Georgia. And he's 13 years old older than the second oldest resident, which is you, the chief resident, right? So he's got that power dynamic already over you, right? And he's three years younger than the program director. So how would you feel being a dynamic that your junior resident is more closing age than your program director? So that's what you're dealt with. And to add to it, in the program, in the entire program, faculty and resident, you are the two black or two colored people in the program. So is there a sense that you have to, you know, there's a sense that you have to make sure that you're in favor of somebody over somebody else, right? So that's what you're dealt with. Here's the issue. The residents have the idea, or they all feel like this gentleman, the 47 year old is coming up and said that he's lazy, he's stardy, he doesn't look as interested as everybody else. They don't think he works as hard as everybody else do. He always does the bare minimum. And they feel like when they approach him, they feel dismissed by this gentleman. So Charles comes to you, you the black, other black person, the chief resident, he comes to you and he says, when you approach him and he tells you that he doesn't feel comfortable taking orders for somebody that has not experienced as much in life, right? And he also tells you that it's you, it's you both against the program, right? We have to help each other up, we have to hide our mistakes or, you know. So how would you deal with that? Is he, what do you ask yourself? Is he being fairly targeted or fairly judged? Are you having a impartial view of the situation? Are you being too partial? Are you ignoring the other resident's concerns? Or are you ignoring his concern that he is even aware that he has concern, right? So it's not a question that as a chief resident I had to reckon with. I had to really take a step back and ask my program director and my superiors, am I doing the right thing? Because I did try to help him. I did try to help him with his work, I did try to be a support for him, but I could hear the other resident in my head saying, why is he getting so much help? Because he doesn't want the help, right? That was the impression of everybody else. Why are you helping him so much if he doesn't care? And in retrospect, I have to admit that trying to identify my implicit biases as the other black person, albeit much younger, I felt like I did work harder than he did. I felt like I did put more into my work than he did. So I had to reckon with that perception of him not doing the work that I did, you know, being a black person. That was the time where I felt really that I had to sit down and think about what am I doing right, what am I doing wrong? So there's a few questions that I asked myself and hopefully I want you to ask yourself so we can interact a little bit more. So is this resident being fairly treated? Has anybody asked him what does he think about the way he's treated? Has anybody asked him why he's coming to work late? Has anybody asked him why do people think he's lazy? Anybody ask him does he have any back pain, for example? Does he have issue getting up? Does he have any medical issue that comes with age? Has anybody actually approached him in a caring way in trying to understand why he's got this reputation? Or as a chief resident in the PAC, what am I doing to understand him, right? What is my role as a chief resident to help him but also making sure everybody's comfortable the way he's being helped, right? Now as a black resident, chief resident, am I being fair, am I playing favoritism, right? I was thinking about me sitting down and trying to identify my implicit biases. But if we put everything into context, the age, ethnicity, him growing in the South, which I didn't talk a lot about it, but he did mention that he had, I didn't say he was angry, but he had a trauma he was carrying, you know, social trauma, he used to call it trauma that he carried upon himself. And he famously said that he's got so many jobs in his life at 47 years old, he's got 47 jobs. And when I sat down and think about it, I thought, did he have so many different role in his life because he did not fit in or they did not support him? Or was it because he was a bad employee? So which is it? So I ask you, how would you deal with that? You know, how would you address a gentleman that seemingly has difficulty fitting in with a group of people? And what would you do to help him? Yeah, sure, sure, anybody, please come in. Thank you for bringing this case up. I don't know if you have the data or if you're gonna show the data that minority ties or people of color, residents of color get dismissed from programs more often due to poor evaluations. So that's like big numbers data, not just your program. And also I found it interesting when you were saying, you know, has anybody asked him, why is he late all the time? You know, why is he feeling lazy? It's putting the burden on him. That is, it's not really opening the lenses to accommodate the idea of structural racism, right? Right. So, and I'm gonna share like in my program, I have, I'm a program director in Florida. I have maybe a handful of residents across the four-year who have not passed step three. The latest of it is an African-American guy. And faculty were saying, is it worth keeping him in the program? And I'm like, well, we can totally have that discussion, but then all of the other four people are gonna be up for grabs and have the same rule applied. Can you go back to the slides of the comments that they make about him? He is tardy, lazy, disinterested. I understand the tardy. That's like very objective. If you're not there at eight o'clock, like I wasn't here at eight o'clock, I'm tardy to your presentation and I apologize. But lazy and disinterested, like what do they mean, right? So that really color the perception. I just wanna put it out there that when you look at national data, there is sort of like a systemic targeting for any BIPOC resident. Right. I'm glad you put that up. I'll mention it later in conference resolution, but I thank you for bringing that up. And by the way, this is a fantastic panel. I congratulate all three of you. These are real, real cases. Just a comment about this resident. When you have people over 40 that maybe, I mean, the same profile, I think you really have to involve the training director because this person's gonna create friction wherever they go. And sometimes the dynamic is why am I, the individual feels demoted. Many times you have people who trained in psychiatry in another country and the residency doesn't count in the United States and they have to retrain and you get a very similar profile. It's like, oh my God, I'm doing this again. I feel demoted. I feel like a little child that's repeating a grade and it's a matter of like sometimes shame and humiliation. And I think that as a chief resident, you're in a difficult position and sometimes you have to kick up this to the training director for the training director to have a conversation with the resident because some of these matters are very personal and they have to do with shame and shame is a very powerful affect and it has to be handled with a lot of care and he's already giving you the indication that he doesn't wanna deal with you because you're younger and that makes him feel ashamed. So I think you have to move it up to the higher ups. Thank you for bringing that up. We'll talk about that. One more comment is how you fell, oh my God, now I have to carry, I have to represent and some of your, it's anger or dissatisfaction that like now you're making me work twice as hard to mitigate or neutralize the way people perceived us because I kind of look like you, right? So it's like that also colors your, you're not no longer neutral to deal with. So it's better to bring in somebody else. All right, please, let me ask a comment. Hi, my name's Elizabeth. I'm a current junior chief resident and rising senior chief resident coming from Virginia. Firstly, just wanted to thank you for bringing this case forward. There's definitely a lot of overlap in some of my experiences that I've had but I did just wanna touch on in looking at the comments that you presented from the co-residents, it's very clear that their statements are coming from a place of judgment rather than a place of curiosity. And I think when we're exhausted and we're burnt out, I think judgment is the path of least resistance and a lot easier to engage in rather than trying to stay open-minded and trying to be curious about what is really going on with him and why is he engaging in the way that he's engaging? I do wonder kind of from your side of things, were there aspects where you felt like you could engage in discussions with some of the other residents to try to fuel that curiosity as opposed to fueling that judgment or were you at a place where you were so burnt out that it was even tough for you to stay curious? Thank you so much. And it's interesting because that's what I dealt with, feeling that I have to be fair and I have to make sure that everybody understands that I'm being fair as a group and also each of them individually. So I had to walk to this resident that made the comments and I asked them, why do you feel this way? Without being curious, like you said, they were saying things like, I work harder, I come earlier, he comes late and he gets it easy. And I'm gonna make sure of all those three comments because I think it ties well together. And the way I tried to deal with it or I dealt with it is that I understood, thankfully, I had good mentorship. We mentioned it to Faria in the beginning. She was very helpful throughout this year as a mentor. So I had the fortitude of being able to sit down and analyze myself first before I went into action and analyze my biases. And somebody mentioned that me being black and him being black and what is the difficulties in treating him fairly and the others in the same way. So I understood that I was already partial. I was already out of the picture in terms of directing the course of action. So I did go into a chain of comment. I did discuss it with the program director and he also had the misfortune of not being able to pass step three. And he had the one last chance to pass it. If not, he would not have been able to practice. So we really brainstormed. We really tried to help him out. We actually, and the group of residents don't know that. We kept it private for his benefit. We actually paid for a course for him. We supported him. We changed the way we mentored him because I felt like we did not really understand the way he was mentoring or maybe he didn't allow us to mentor him. And we changed his mentor to somebody that older in age than he was. And also somebody that was an immigrant, somebody that would understand where he's coming from. We also gave him the opportunity to get a mentor outside of a department that he doesn't have to tell us who it was. So he could feel more comfortable just talking and venting about things. And I think at that point, you understood that he was supported. I'll be honest with you, I'm not sure how the other resident felt about him being supported, but I think in retrospect, we did the right thing by him. And one thing I wanna add, the other residents, I think they'll grow in time. They were a junior resident first and second year. And I think hopefully they'll see that interaction as a point of, as an opportunity to learn, right? But one thing I wanna add that's important, during the discussion and this problem that we have with this resident, I felt like nobody really valued his value, what he brought to the program. At a few times he mentioned that he was old. He even said jokingly that he had back pains, he cannot wake up early enough, but nobody actually asked him or see him as a benefit of the program. He mentioned that he has a lot of different experience in life. So what we could have done better is maximize his experience, right? Have him be part of the program in terms of teach us what he's gone through in life, right? Have him representation on systematic racism, something that he would feel included in, right? And I think that's something that we could have done better maximizing his benefit. Earlier I mentioned the biases, which is the horns effect is when you overvalue the negative aspect of someone and not being clouded and not seeing the positive traits. So I think there was a lot of horns effect with myself, with the program, with the residents that we did not give him the opportunity to show his value to the program and we focused more on his shortcoming. I guess I was a long answer to tell you that it was challenging for myself as a black person, yeah. But I thought I went up in a hurricane and I seek help. Thank you for such a well thought out answer. I particularly love the fact that you guys were able to modify your mentorship structures because I think in my personal experience, anytime we've navigated new situations, the blame is then put on the individual as opposed to taking a look inwards and acknowledging the fact that we do have an opportunity here to create structures that can benefit future residents as opposed to just viewing it as a problem in the short term. All right, well thank you. Thank you for the question. Thank you. Since a couple of individuals trickled in late, so let's go back to the beginning how this all evolved, right? So we founded Ripple, Residents and Psychiatric Programs Leadership Experience back in 2021, managed it through the district branch in Florida. As you know, Florida's a geographically dispersed state, very big, and it was a specific chief resident leadership experience to help incoming chiefs and it was meant to be a mini longitudinal skills-based training which starts with a lot of leadership training with self-reflection. You can see how chiefs are very reflective and that's not a new model or paradigm for leadership, right? But how it was really exemplified by our illustrious panel here. As part of that is convening each of the two cohorts had 21 chiefs across the state, right? And Dr. Deferia being from the University of Florida in Gainesville, mentored this wonderful group and as part of not only the didactics but also the coaching sessions, right? And that's where the skills building came in. They took it upon themselves and as part of that to take the initiative to say, hey, not only are we reaping the benefits of this wonderful experience where we've dedicated our extra time to grow professionally and maybe even grow personally and look at ourselves as our multiple parts of our identity, right? As individuals, as physicians, as psychiatrists, as chief residents, as minorities, on and on and on and how they could then go beyond the program to look at sharing these wonderful experiences and challenges with everyone. It was under the mentorship of the small group leader, Dr. Deferia, who is now, as I exited Florida, who is now the program director, who went and really introduced the concept of diversity, equity, inclusion, and bias, which was embedded in the program but really elevated it programmatically to be an important common theme and goal and outcome of the program. And so part of that, by the way, the program received an honorable mention as a best practice from the APA. That means you're number two. You're not quite, you didn't get the gold star but honorable mention last year as a best practice but it really is a model of how to help individuals grow, how to help validate that the concerns and very disparate and different programs are similar, how to help create a networking opportunity, a leadership development opportunity, an opportunity for not only vertical mentoring but peer mentoring as well. And so there's all these layers and that's the proverbial ripple, right? That as a chief resident, you're like a stone in water and you influence out but it's also the program influences out in multiple, multiple domains or areas. So that's a little bit of context of how this all developed because as you can see, you have one, two, three, four programs across the state of Florida, right? And now there's about 21 residency programs in Florida. And I wanna say Florida now is not a respective place to discuss this. Remember this is being recorded, nothing about Disney. No, I just wanna say it is a challenge and I'm so happy we train people to keep those issues in mind because I think that there is even more likelihood of creating silos and making people feel alienated and not seen. So I think that there was like in this nick of time that the cohort that did ripple really debated that. And so for that, I'm very happy. Any other final and closing comments? We appreciate everyone being here because we think this is not only important speakers, right? But also an important topic and we were glad for this opportunity to be able to share this with you. Yes, please. I love this, this is really beautiful. This needs to be disseminated at a national level. I'm curious for the three of you, what's the biggest change that participating in this leadership training and then actually putting this in practice, what's the biggest change for you? How has this impacted you and changed you? Excellent question. Ladies first, go, go, go. I think that's a great question. And I think for me, it helped me grow personally and kind of look at things from, I mean, it was great getting perspectives from one males, chiefs from other programs and also Dr. DeFaria from as being a woman, as being a working mom, all the above. So I think the most helpful thing was getting those perspectives and the different points of view and being able to use that and kind of look for those other opinions and look for mentorship really in other issues that have come along throughout the year. I think if I didn't mention it, I'll say it again. I think personally, the program and the mentorship and the meetings that we've had throughout the year really helped me grow exponentially. It's like you put something in the food and it tastes totally different. I see things differently. I'm able, I think I try to be able to reflect before I say things, before I do things. I think I'm more conscious in trying to acknowledge my own biases, being more self-analytical. But the other part of the program that I also think I benefit very much from is being able to network and meeting wonderful colleagues and meeting with Dr. C, Dr. Castellanos and Dr. DeFaria and learning from them have opened so many doors for me and I think throughout this program, I think I mentioned to DeFaria once that I think I found my voice that I didn't know I had and I built an interest into policies and into trying to make changes in hospital management and I was invited to sit on diversity committees in the hospital and thankfully to that presentation, I was accepted at the Morehouse Scholar Program. So I think the fruit that I'm getting from it is like leaning on others, learning from elders and leaning on others and also being vulnerable to change and to be able to recognize how we can change. For me and I always take too long on the mic so if anybody has to shut me off, shut me off. But for me on a professional level, it was the being able to see other perspectives, get new ideas for my program and be able to give ideas for other people's programs. It really was kind of the, nobody really prepares you so much of what's gonna happen when you become chief resident. The whole popularity drop, the whole you're gonna have to be awake sometimes at 3 a.m. redoing a schedule because somebody called in sick last minute and a lot of times you feel alone because you're no longer just another resident. They exclude you but you're also not faculty, staff. You can't go into the faculty lounge and you know, drink the Coke. So, but it's that sudden feeling of sort of brotherhood that you get with other chief residents from across. It's that feeling of friendship, of you're not alone in this. This is how we faced this before or I don't have this program because we already have this and that just companionship of not, you're not alone in this. There's other people that either went through this years ago or going through this now with you or will go through this in the future that I can't understate the value of that specifically. Being a chief is sort of alienating yourself from two worlds and then choosing to walk a very different path and then just knowing that there are other people in the same path with you to be able to give you different perspectives, ideas, friendship, just unspeakable and it's emotional for me. I'm gonna take this brief extra five seconds to thank everybody who's here. Thank all the previous chief residents of any program and any specialty that have been before for passing down the wisdom and to any future chief residents or current chief residents, just thank you all for choosing this path and for being here and I hope that this presentation someday in some way or form reaches everyone and that we can all contribute to grow. I just wanted to share one little quote based on the whole minority issues that we're having now and everything. It's one of my favorite quotes from the work but it's basically says, you know, we do have a lot in common. We have the same earth, we breathe the same air, the same sky, the same water. Maybe if we all just start looking at what's the same instead of what's different, you know, who knows what we'd be capable of. Oh, great. Thank you. Thank you for that. Thank you. And I will close with what are my typical and African proverb. If you want to go fast, go alone. If you want to go far, go together and together we shall. Thank you everybody. Thank you, thank you so much. Thank you.

Leadership Development

Chief Residents

Diversity Equity Inclusion

Mentorship

Psychiatric Programs

Implicit Bias

Ripple Program

Gender Bias

LGBTQIA2S

Medical Education