Well, good afternoon. And sorry for the delay, but it is 4 o'clock. So obviously, somewhere people are saying, where's the tea and coffee and pastries? So I want to thank you all for being here today. I'm Saul Evans, CEO and Medical Director of APA for three more weeks. And then we're going to have an amazing CEO and Medical Director taking over from me. You're going to love her. She's truly just wonderful all around. Her knowledge, the way she deals with people. I leave APA after 11 years saying that we are in really good, sound hands. So please, when you get to meet her, just really introduce yourselves, who you are. With many of the people here, I have a feeling we'll want to get to know her because she's very clear in terms of ensuring that everyone should be treated equally in this organization, and particularly in terms of what we call, I wish they'd change the name, minority and underrepresented groups of APA. So thank you all for joining us this afternoon for our session on racial, gender, and sexual orientation, microaggressions experienced in health care, and strategies to overcome. We find ourselves at a pivotal moment when the importance of addressing systemic biases and injustices within health care has never been clearer. Oh wait, I forgot to do the land acknowledgement, didn't I? So let's go back to the land acknowledgement. It is with gratitude and humility that we acknowledge that we are learning, speaking, and gathering on the ancestral lands of the Munsee Lenape people, who are indigenous peoples of this land. Despite tremendous hardships of being forced from here, today their community resides in Wisconsin and is known as the Stockbridge Munsee community. We pay honor and respect to their ancestors past, present, and we commit to building a more inclusive and equitable space for all. And I think this is exactly what we are going to be talking about today, that everyone should be treated equally, and with compassion, and always helpful despite whenever they did need help. We find ourselves at a pivotal moment of the importance of addressing the systemic biases and injustices within the health care has never been as clear as what it is today. We know that racial, gender, sexual orientation, minorities face unique psychosocial barriers to care. Limited access to services, with limited access to services, discrimination, prejudice, and microaggressions. Microaggressions can have a profound impact on patient, physical, and mental health outcomes. They erode trust between patients and providers, hinder open communications, and contribute to disparities in health care access and quality. Likewise, health care providers who belong to minoritized groups may themselves experience microaggressions in their professional environments, leading to stress, burnout, and diminished job satisfaction. It is our hope and through our conversation here today that we are able to acknowledge the presence of microaggressions and affirm our commitment to adapting strategies that foster a health care environment that is inclusive, equitable, and supportive for all individuals, especially for individuals who self-identify as a member of racial, gender, sexual, orientation minorities, as well as other intersectional diversity dimensions. The people we're going to be hearing from today are amazing speakers, and particularly on the topic. So the first will be Dr. Ravi Chandra. I'm just doing an alphabetical now, and then we'll go in order of their presentations. Dr. Ravi Chandra is a psychiatrist and writer based in San Francisco. Thank you for being here. Dr. Fee Fonseca is a consultation liaison psychiatrist in the Mayo Clinic. She also sat on the board, and she was an amazing board member of the Board of Trustees, where she really represented, I think, all of us minoritized groups very eloquently and always stood up when people would begin to start going down a path where they shouldn't. She always knew just how to pull them back in. And then finally, and last but not least, is Dr. Dhruv Gupta, a forensic psychiatrist with the New York State Office of Mental Health. Clearly also another rising leader and star. One day we'll hope to see all three of you as presidents of the APA, as I go into my dotage. So well, it happens to all of us. So I'm going to just do one quick thing, if I can, talk about one quick thing. Microaggressions come and we often ignore them. I've been the CEO, medical director of APA for 11 years now. I'll be ending at the end of May. I still have members come up to me and say, how's your wife and kids? It's like 11 years. They've known me. I'm very clear. I'm gay and an international medical graduate. And it's amazing how I think sometimes they're just purely blind or they just either don't care or they just surmise that everyone is just like them. And in some ways, I do say APA's organization has really changed both the staff and I hope at least the leadership, and you do see it in the leadership getting better and better, to ensure that they find out how do you want to be addressed? How do you want to talk about who you are? And it has really helped even on the board, where at times, because we have different board members coming from both the left and the right of the political spectrum, that even those who may not see the need to ensure that everyone gets treated with respect and addressed the way the person would want to be addressed as. And I've got to give the board of trustees, they've done a number of trainings, and they've really stepped up in this to try and do it more. So in some ways, as we sit here today, at least we know that our leadership, and the assembly as well has done a lot of this as well, is that it's also a learning process. And while we've got to be patient, there also is a time when you have to start saying, it's enough enough being patient and address it. So now when they ask me, how's my kids and my wife, I say, I thought you knew that I'm a gay man and I'm also an IMG, to add to it. I'm very proud of both of those two. And I think that's what we're going to talk a bit about today. Listen to experts sitting on the panel. Thanks, OK. So disclosures, I'm currently the medical director and CEO of the American Psychiatric Association, and also chair of the APAF, the Foundation Board of Directors. And it was one way that we could keep the two organizations close together was by having that. And also, our treasurer sits on it, and our president-elect, and our past president also sits on that board. So we always ensure that some boards, when you do split it, begin to diverge away. This keeps us all really bound together, that the foundation is the philanthropic arm. We have Drs. Chandra, Fonseca, and Gupta do not have any financial conflicts of interest to report. I have one conflict or two conflicts to actually talk about. One is, actually, I'm already in the position as the secretary general for the World Psychiatric Association, although I told them I'm not going to be able to take up the job till the 1st of June. So officially, that's when I will become very active there. And also, obviously, as a gay man, I'm fairly active within the gay community as well. And I've sat on different boards on that. So with that, I'd like us to go to the next slide. And here are going to be the wonderful speakers that we're going to be hearing today. Ravi Chandra, and I'm going to ask each of you to present how you want to be presented, how you like to present yourself on it, followed then by Fee, Fonseca, and then Drew. Are you going last, or are you going to go first? Did I go the wrong way around? No, it's in the right order. Good. Thank you. And Drew Gutter, who's clearly one of our, as of all the three panelists, on the rise of one day, hopefully becoming major representatives of the APA, and also of their specialties, and more importantly, also of their communities which they came from. Thank you. Thank you, Dr. Levin. Thank you very much, Dr. Levin. So really quickly, our objectives will include appraising evidence-based literature on racial, gender, and sexual orientation microaggressions in health care, identifying racial, gender, and sexual orientation microaggressions experienced by patients and health care providers in the United States, evaluating health and mental health consequences of microaggressions, and then finally, we really hope to have ample time to discuss effective strategies with everyone here that's present to mitigate the deleterious impacts of microaggressions that are experienced in health care. In favor of time, I will skip over this slide, but essentially breaking down the objectives and what we hope to establish. So with that, I would like to ask my colleague Dr. Fonseca to tell us more about microaggressions. Good afternoon, everyone. Thanks for being here. We're going to try and fly through this as soon as possible so that we can get to really the meat of our discussion. So before we talk about microaggressions, I wanted to touch on the concept of intersectionality. So legal scholar and justice advocate Kimberly Crenshaw in 1989 described the experiences of black women who faced intersecting forms of discrimination based on race and gender. And intersectionality really talks about the interconnected nature of social categorization, so things like race, class, gender, as they apply to a given individual, but also to groups. So this is a theoretical framework. It describes how multiple social identities intersect and interact with one another and create overlapping but also interdependent systems of discrimination, disadvantage, or privilege or advantage. And all of these forms of oppression really reinforce one another as well, and the effects are compounding. So let's see if I can figure this out here. OK. Haven't done Google Slides for a presentation before. So the other topic that I think folks need to know about and be educated about is cultural humility. Oftentimes we talk about cultural competence, which is really a bit of a pitfall in some ways when we look at things that way as being able to easily demonstrate some sort of mastery of this finite body of knowledge, where really we're called to approach things from a place of humility, where we're active, engaged, there's a lifelong commitment to self-evaluation and education, self-critique, and also a commitment to addressing power and balances within every relationship, not just the clinical one. And then eventually the long-term goal is to develop these mutually beneficial, non-paternalistic advocacy and clinical partnerships with communities on board. So we need to be practicing all of our encounters with this integrative intersectional lens, also with cultural humility. So the term microaggressions was actually coined by Dr. Chester Pierce, who's a Harvard psychiatrist, described the continuing stain of racism, really, which continued and actually still continues in a lot of ways following the Jim Crow era. So Dr. Pierce says that the most grievous of offensive mechanisms spooted victims of racism and sexism are these microaggressions. They are subtle, innocuous, pre-conscious, or unconscious degradations and put-downs, often kinetic but capable of being verbal and or kinetic. In and of itself, a microaggression may seem harmless, but the cumulative burden of a lifetime of microaggression can theoretically contribute to diminished mortality, augmented morbidity, and flattened confidence. So how do microaggressions happen? Microaggressions happen due to various factors, including unconscious biases, attitudes, and beliefs that we hold without being aware of that influence how we interact and perceive others. Stereotyping, generalized beliefs about groups of individuals, socialization can also play a role here, social norms, expectations that we, at some point, imbibe from families, from cultures, peers, media. And there are different types of microaggressions. So you have being treated kind of like a second-class individual, the micro-insults. They're more subtle. Their intent isn't necessarily to harm. It can be rude, insensitive. That just kind of demeans a person's identity or credibility, kind of wipes them away in some ways. But then on a level above that, you have the micro-invalidations, and those directly deny the reality of groups to create a homogenizing effect, kind of like a cultural gaslighting in some senses. So it can be really quite damaging in the long term. And then we have micro-assaults. With that one, the intent is explicitly to harm and to threaten, intimidate, make individuals or groups feel unsafe in some way. And it's really similar to kind of the old-fashioned racism, sexism, that sort of thing on an individual level. But they're expressed in a way that offers the perpetrator some kind of protection. So if it was to be kind of brought into the open, they could quite easily deny it. We think about this as kind of like death by 1,000 paper cuts. Because these, especially the micro-insults and micro-invalidations, are so subtle that they're really challenging to address. So neither someone's experiences, someone's identity, or the ways that they enact these micro-aggressions exist in a vacuum. So it's relational, you know, this process between history, culture, and the moment in front of us. And so I wanted for us to also think about, I'm gonna skip through this slide, structural competency, which requires that clinicians are familiar with the structures that impact health and the provision of care, and able to include structural factors in their formulations. And this concept was largely written about by Dr. Helena Hansen, who's also a psychiatrist. And structural competency asks us to kind of evaluate the infrastructure, the health system structure, the legal structure, the diagnostic structure, too. And especially for us as psychiatrists, the way that we maybe interact with the DSM and reflect on how we use that with our patients, too. And all of these can contribute to minority stress. So minority stress describes high levels of stress faced by members of stigmatized, minoritized groups. So on a background of generally just being alive in an environment, you have the historical context, social roles and expectations, legal threats. And then you have general stressors like housing issues, living through a pandemic. And then you have the minority stress processes. All right. Distal or external discrimination, violence, structural stigma, and then as a result of that identity or self-identification with these negative messages, you have internalized stigma as well. For example, internalized racism, gender dysphoria, things like that. And then coping and social support can kind of mediate that, but all of this really impacts health outcomes. So how does this play out in healthcare? A key difference really is the power dynamic between the patients and the clinicians, where a lot of the examples on this slide are race-driven, but we can generalize this concept to other forms of discrimination, too. For example, the trans broken arm syndrome, when someone comes into the ED and they're transgender and they're asked really intrusive questions about their gender experience that are not relevant to the actual examination. And even with race, when we think about folks who come from mixed backgrounds, monoracial assumptions can often erase their identity, family dynamics, and limit who they are in that kind of encounter. For queer folks, there's a lot of use of heterosexist terminology, maybe heteronormative approaches to interaction, assumption of a universal queer experience, eroticization, discomfort with the disapproval of their existence, et cetera, all sorts of things. But unlike everyday experiences of microaggressions in which you can kind of ignore or disregard a stranger's comment or question to some extent to kind of make it through the day, in the context of seeking healthcare, patients cannot do that. And they don't even know kind of how to address that with their clinician. A lot of the times they are unable to tell, you know, is my clinician asking this because they generally need to know this? And that sense of a loss of power really adds to this and compounds it. So we have racial trauma, which is the mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes. Any individual that has experienced an emotionally painful, sudden, uncontrollable racist encounter is at risk of suffering from a race-based traumatic stress injury. And experiences of race-based discrimination can have really detrimental psychological impacts on individuals, on their communities. And in some individuals, prolonged incidents of racism can lead to those that are very much like PTSD, and I would argue are a form of PTSD. So you can have direct traumatic impacts of living within a society where there is structural racism or being on the receiving end of individual racist attacks, be they micro or macro. And then you have vicarious experiences as well where those in your community, loved ones, are going through this and you're kind of going through it with them. And all of these can be associated with epigenetic changes and can be then kind of handed down through the generations as a form of inherited trauma in some ways. So allostatic load is just a concept used to describe cumulative wear and tear on the body. It's influenced by a variety of factors, the body's stress response system, including the HPA, hypothalamic pituitary adrenal axis, and the sympathetic nervous system can become really dysregulated over time as a result of chronic stress leading to inflammation, changes in hormone levels, other physiological changes that can impact health. And the unfortunate reality is that microaggressions are going to happen. It's not a matter of, you know, is this going to happen? It's a matter of when is this going to happen? And folks who experience this experience them on such a regular basis that it's nearly, you're constantly on edge waiting for the next thing. So recurrent microaggressions, again, can cause allostatic overload, which can result in decreased cognitive reserve, decreased efficiency, increased burden on attentional resources, decreased mental and physical health, and is really associated with a range of problems. So trying to reduce allostatic load, it's really nice to kind of talk about things in these abstract, theoretical, neurobiological terms, but how do we actually operationalize this? We need to be really addressing these underlying issues, right, these underlying pathologies within the way that we have structured our culture, and addressing ways to maybe change the social, economic, environmental factors. So thinking of it really as a macro issue for us to all work together at whatever level we're able. So I have this slide here, because I think it's important for us to know that oppression always involves harm to some, but also benefit to others, and that it's always going to be rooted in history, it's systemic, it's structured. And our system isn't broken, it's functioning exactly how it was designed to function, and serving exactly whom it was designed to serve. And it's on us to be a part of restructuring and improving it so that we are not complicit in the harm it has caused and continues to cause, because any sort of techniques, interventions to address stigma and discrimination, and improve outcomes will fail without an understanding of the root causes, the systemic issues that are underlying oppression. And just a call on all of us, we're psychiatrists, we have so much power, especially in the field of mental health, and being able to kind of use that privilege in a way that advances our field and makes a positive impact. So, with that said, I'm going to hand it over to my colleague, Dhruv Gupta. Thank you. Thank you, Dr. Fonseca, for outlining so comprehensively the types and themes of microaggressions that are frequently experienced by racial, gender, and sexual orientation minorities. I am Dhruv Gupta, and I have the pleasure of talking about the health and mental health consequences of microaggressions. But just before we get started to doing that, I wanted to take a moment to really talk and point out, why is it that we talk about microaggressions in the field of medicine? Even though we are looking at it from the level of the individual, we work as teams in medicine, and we take care of patients as teams, and the health of even one person within a team affects the entire health of a team, and affects patient care. So it's very much central to patient care, well-being, and there's ample literature on health and mental health consequences of microaggressions. And time permitting, you'd have a lecture, two, three, or even more, four, five, just on the health and mental health consequences of microaggressions. So to just move on briefly, talking about, from an overview standpoint, at a broad level, experiencing a microaggression signals the presence of a dangerous environment that results in physiological and psychological stress responses. And a cumulative burden of a lifetime of microaggressions, especially that experienced by minoritized populations, create a state of perpetual stress that can contribute to physical and mental illness, and flatten self-confidence, relating back to the concept that my colleague Dr. Fonseca pointed out on allostatic load. And it's to be remembered, microaggressions are cumulative, and any one offense or put down may represent the straw that breaks the camel's back. And we'll come back to that point in a bit. So I always like to get started with pointing out, explaining this diagram from a highly cited meta-analysis by Pasco and colleagues that points out the relationship between perceived discrimination and both mental and physical health outcomes. So let me orient you to the oval boxes and the varied pathways. So before I do just that, let's go back to the oval box that says perceived discrimination. Microaggressions can be viewed as perceived discrimination because Dr. Chet Pierce defined it from the perspective of the recipient, the target, the person who was subjected to that statement, that was a microaggression. And going forward, so there's two different mechanisms by which microaggressions perceive discrimination manifest their health and mental health consequences. So let's start off by looking at pathways B and C. So one way in which it occurs is that the mental and physical health consequences are mediated by a state of heightened stress response. What it means is activation overdriving the hypothalamic pituitary adrenal axis that results in downstream consequences. On the flip side, pathways D and E, which result in mental and physical health consequences, are mediated by the individual engaging in adverse health behaviors, behaviors that are not health conducive. And the great thing about this diagram is even though we come back to strategies, if you look at the lower left oval box that identifies the point at which strategies can actually make an impact, social support, stigma identification, coping style. It's well before you even have those physiological responses that result in the downstream health and mental health consequences or the individual engages in adverse health behaviors that then go on to have downstream effects. So let's start off by taking a closer look at some of the health and cardiovascular consequences. There's a whole body of literature to support the adverse cardiovascular consequences of microaggressions. Perceived racial ethnic discrimination is linked to poor health, coping behaviors such as higher rates of smoking, excessive alcohol consumption, and illicit drug use, which of course increase the risk of cardiovascular disease. And there's consistent evidence from the literature that suggests a strong link between perceived discrimination and blood pressure reactivity and hypertension. Perceived discrimination is also associated with poor heart rate variability. And experiencing racial microaggressions has been shown to result in same-day elevated cortisol levels, which go on to suppress the immune system and response to the body's defense mechanisms to infectious agents. And interestingly, there are studies out there now that are actually looking at the biological mechanisms of microaggressions as well. In a highly cited study, Kershaw and colleagues noted that higher lifetime levels of discrimination were associated with elevated levels of interleukin 6 and C-reactive protein, which are both pro-inflammatory markers. So microaggressions can result in a wide array of mental health output. Some of these are symptoms, but there have also been studies that have been correlated with various diagnoses as well. These range from PTSD to OCD to substance use to suicidality and homicidality. Now let's take a moment to look at a couple of studies to get a better sense of the mental health consequences of microaggressions. We just talked about symptoms and diagnoses, but another thing that doesn't get really talked about is that microaggressions contribute to barriers of treatment. It undermines trust. In a study by Williams and colleagues, they noted that microaggressions undermine trust such that individuals of color will avoid care or wait to seek care till concerns become severe. Similar to our last study that we spoke about, Smith and Terrell noted that health care providers oftentimes because they receive little to no formal training in LGBTQ plus health competencies and due to that, they inadvertently make statements that result in microaggressions that create discomfort for LGBTQ plus patients who may then go on to miss health care appointments, withhold important information from the provider, and frequently even change providers or avoid health care altogether. I've put in these diagrams to just show which path we are following through. This would be, again, engaging in a maladaptive behavior, the microaggression experienced by the individual results in them not making their appointment, not disclosing the information that they need to. In this particular study that was published in the American Journal of Public Health, Sawyer and colleagues demonstrated that merely anticipating prejudice can lead to both psychological and cardiovascular stress responses, even without behavioral confirmation. One of my favorite studies that I've come across in the sense that they informed Hispanic women, Latina women, that they are about to engage in an interaction with individuals who harbor negative views towards members of their subgroup. Even prior to having interacted with them, there were elevated physiological and cardiovascular responses that were noted. What was also noted was their sympathetic nervous system through their hypothalamic pituitary adrenal axis activity was elevated and that resulted in increased allostatic load over time. This is a fine example of Pathway B, where there was a resulting heightened stress response. Let's shift to taking a look at the impact of microaggressions on trainees that are training in healthcare. In 2020, Molina and colleagues examined the perspectives of nursing and medical students that are underrepresented in medicine. Students thought that racial microaggressions negatively affected their learning, academic performance, and personal wellness. To me, what's most interesting is the fact that racial microaggressions not only devalued their experiences, but also negatively affected their learning, academic performance, and personal wellness. They went on to redirect them to engage in activities where they would go on to take on the role of educating others about what happened. By doing that, they become a race ambassador. They become a spokesperson for their race, ethnicity, or culture. That is what's called the minority tax. Over time, engaging in that multiple times, that then results in what's called racial battle fatigue, which occurs time after time, having to experience microaggressions and then take on that role of becoming a race ambassador, becoming that individual who is going to be the spokesperson to educate. This results in psychological stress responses, such as frustration, anger, resentment, or fear, physiological stress responses, like headaches, tachycardia, hypertension, disturbed sleep, additionally behavioral responses, such as impatience, poor academic or occupational performance, or stereotype threat. Going back to the Molina study, the most captivating piece to me is that due to their often subtle nature, the recipient of microaggressions is frequently left trying to comprehend their experience and unable to express the effect of these exchanges. Why is that? Because the person doesn't necessarily know the intent. Does this person know it? When it's overt aggression or overt discrimination, you know what has just transpired. But when a person of color finishes grand rounds and there is a comment such as, that was a very eloquent presentation, or I didn't expect that, that results in the person thinking, was that a compliment or was that a backhanded microaggression, or it was a microaggression in a way. That state of confusion of not knowing and not being able to express yourself actually goes to cause even more damaging and destruction than the impact on the mental health just due to the nature of the microaggression. Even though the word is microaggression, the micro does not mean small. It's differentiating it from overt prejudice and discrimination because of its nature. As my colleague, Dr. Fonseca pointed out, micro is not small. They can contribute to death by a thousand cuts. And these are just my references. And with that, I will pass it on to Dr. Chandra to talk about caste and power. Thank you. Thank you. All right. Let's see. Okay. Yes. Thank you so much. And it's such a pleasure to be with my distinguished colleagues who put me through my paces over the last year. So I hope this next segment will entertain and enlighten you. And thank you all for being here. Oppressions are so alarming and unsettling because they pour salt on the wounds of existing oppressions and dangers impacting identity, wellness, belonging, and meaning. And to be most compassionate and generous, they arise out of a blind spot in the dominant culture which doesn't understand or see marginalized identities. They are a product of an empathy hole. And I define emotional exhaustion as coming up against an empathy gap, an empathy hole. So to understand how the social and political environment impact us, I'm going to make a dark joke based on the experience of one of my patients. The IDF causes IBS. Okay. So my Palestinian-American patient linked their worsened irritable bowel syndrome symptoms to the war in Gaza. And of course, Jewish people have been deeply impacted by October 7th and the aftermath in antisemitism as well. What's happening in Israel, Gaza, and Palestine is a concrete example of overt violent conflict and competing ideologies. But as minoritized communities, we have experienced historical violence through colonialism, slavery, genocide, and ideologies of hierarchy illuminated most recently by Isabelle Wilkerson in her book, Cast, and in Ava DuVernay's film adaptation, Origin. This lives on in Psyche and Soma. The perceived devaluations and slights land on these wounds. The summary of what I think we struggle with is top-down hierarchical authority, the guard tower. Okay, so as humans we all arise from vulnerability, precarity, and our shared humanity. This requires relationship, dependence, and interdependence. But I think this vulnerability, oh sorry it's kind of split up there, but this vulnerability fosters a split, what I call the basic split, essentially between haves and have-nots, the powerful and the disempowered, the socially dominating and the subordinate. Here we have Balint's basic fault, the dearth of love, there we go, all right, the dearth of love in early experience and all that can arise from it. This basic split is intrapsychic, interpersonal, and societal, responding a flight or a fight-flight response to fear, vulnerability, uncertainty, and doubt. We can flee into dominating power or develop compassion and relatedness. The guard tower of the dominant culture looms above us all, an invisible torment in the collective psyche. Rising from judgments, bias, and the absolute need to elevate a leader and an elite, it looks down on the rest of us in contempt. You could call it a punitive superego or the dominant culture's critic and enforcer. It perpetuates and transmits trauma. Microaggressions are the tip of the iceberg, the tip of the spear. The guard tower arises from fear, specifically a fear of relationship, because relationship means change of identity, of control of everything, and let us be tender to this fear as it may also be our own. I wanted to play three short clips from the film Origin, based on Wilkerson's cast, to illustrate the points I've made. Okay, so this is from Origin. Nazi Germany was, in fact, inspired by the United States. These are the minutes from the meeting in 1934. 15 months after the meeting, they become law. Jim Crow laws. Yes. And we can erase laws. Yes. It's mind-blowing. Deutsche Juden sind viel zu arrogant und zu überheblich. Unser Problem ist anders gelagert. Our problem is different. Their problem is Negroes with nothing to build upon, a problem that plays no part for us here in Germany. Our problem is the Jews who must be kept enduringly apart. What is this? That is a transcript of a meeting that I saw a picture of, where Nazi lawyers were studying American law and customs to figure out how to pull off the Holocaust. Our problem is the Jews who must be kept enduringly apart, since there is no doubt that they represent a foreign body in the Volk, and segregation will never achieve the goal as long as the Jews have economic power in our German fatherland as they do have now, as long as they have the most beautiful automobiles, the most beautiful motorboats, as long as they play a prominent role in pleasure spots and resorts and everywhere that costs money. This can only be achieved through measures that forbid sexual mixing of a Jew and a German and imposes criminal punishment. We must answer the question today as to whether laws that the Reich will institute should declare only the separation of races, or if it should declare the superiority of one and the inferiority of others. In the fall of 1933, Allison Davis and his wife Elizabeth cut short their advanced studies at the University of Berlin and fled Germany when Hitler took power. Well, we finally got proof that one landowner named Bailey has been whipping sharecroppers. Bailey's wife told me that's the way to manage them when they get to Uppity. We heard about a tenant farmer, one county over, who was beaten so badly by a store merchant he can't bring in a crop. We're heading over there tomorrow. Do you know what sparked that? The Negro man asked for a receipt. Read him right there in the store. It inspired him to study the process of injustice. This gave Dr. Davis new insight into the nature of hate. All right, and this is another clip about Dr. B.R. Ambedkar and cast. To us, he's revered. To others, very violent. Dr. Ambedkar's statues are one of the most vandalized in the country. The cage is to keep the vandals away. Dr. Ambedkar is more than a champion and a hero to the Dalit people. He's the hope that lives within us. He went into the heart of the problem of caste and he saw purity was lying beneath the artifice of caste and where the human population was chopped into what he called fixed and definite units. In America, you have what you call the blacks, the brown, the Asian, the whites, and etc. Similarly, we have in India where the Dalits are supposed to be at the bottom and the Brahmins at the top and between there are various units of caste. What maintains this unit into continuing of caste system is the unending violence in the form of rape, mutilation, and murder. In India, a Dalit person is attacked every 15 minutes. Every day, 10 Dalit women are raped and these are only the reported cases. Rohit Vemula's friends, family, and the wider Dalit movement called it an institutional murder and they called it this because it was not simply a case of suicide. They said that this was an institution that was systematically discriminating against a young Dalit student and this was important because for a lot of us as young folks who were looking for a life of dignity and respect and were looking to education and the university to give us that life, it showed that the specter of caste was still haunting us. In a world where Dalit people are brutalized simply to keep us in our place, Dr. Ambedkar remains our shining light, our guardian, our hero, our father. The site of Dr. Ambedkar's last home is a museum now. Quite magnificent. As you can see, it's an open-book concept. And this is the connection of Dr. Ambedkar and the struggle of Dalit people to Martin Luther King. With race. Oh yeah. If I brought you to the family reunion, what would you say? What would you say to that? My cousin Mary, my mother. What would you say to them? That's important for them to know about you, about India, about caste and our connection. Our heroes found the connection and it is up to us to find it again and build upon it in sibling solidarity. When Bhimrao Ambedkar was a young Indian graduate student, he found himself in New York City. Harlem, to be exact. He saw kindred spirits among black people in America, both in the oppression they faced and in their survival. He immediately recognized the similarities between how African Americans were treated and the treatment of Dalits. Asha, you've been doing some work on this one, right? Yes. My thesis centered on Dr. King's visit to India. He saw many of these things firsthand while he and his wife toured the country. I found the way in which he wrote about India to be fascinating as someone afflicted by caste in their own country. I used his essay in the magazine of United States as the core of my research. Do you know Ebony magazine? Yes, yes I know Ebony magazine. Dr. King wrote about India in Ebony? Yes, July 1959. It is quite extraordinary. And so there is a connection between us, the African Americans, the Dalits, the indigenous people around the world, Palestinian people, the Roma people, the Buraku people. The outcasts of Africa are still fighting for their rights, be it Nigeria, Ghana, Senegal. You go to Latin America, you find outcasts within the Mexican society or Brazilian society. And if we think about our histories through the vulnerability of love, the symbols of hate and diets of violence will be replaced by compassion, care, and solidarity. This is the world that we have to imagine for ourselves and for others who have not yet seen the beauty that human beings have to offer. One afternoon I went down to speak in the southern part of India and I remember that afternoon that the principal got up to introduce me. He said I would like to present to you a fellow untouchable from the United States of America. And for the moment I was peeved, I was shocked that I would be introduced as an untouchable. Pretty soon my mind ran back across to America and I had to say to myself I am an untouchable. Segregation is evil and sinful because it stigmatizes the segregated as an untouchable in a caste system. This is why I'm convinced that we have a moral edict, a moral mandate to work to get rid of this unjust and evil system. And finally Dhruv made a special request for me to show the next film about another kind of power to replace the guard tower with a more nurturing power. So this is a short film I made about my own mother. We're gonna win with strength. We're gonna win with health. We're gonna win at so many levels. We're gonna win, win, win. You're gonna get so tired of winning you're gonna say Mr. President please we don't want to win anymore. It's too much and I'm gonna say I'm sorry. We're gonna keep winning because we're gonna make America great again. Winning is follow your passion. If you accomplish that is winning. Okay well do you have to be responsible to other people? Of course. When you do follow your passion you should be. You must be responsible for others too. You cannot be selfish. Is Donald Trump a winner? I don't think so in my viewpoint. It is up to him to think what he is. What do you think? I don't think he's a winner. Why? Because winning is not getting a position or power. Those kind of things. Winning is... I don't know what to say about him. For me he's not a winner. Okay but you said he won because he achieved the presidency. Yeah he may wanted to be a president. He achieved his own passion probably. Okay but what then why isn't he a winner? I don't know. My point is serving the public, fulfilling the ordinary people desires and serving humanity. And what about... oh sorry go ahead. Serving humanity. I don't think he served the humanity. He served himself. And what about you? Are you a winner? Of course I'm a winner. Why do you say that? Because you know that what I wanted to be. I worked with the poor people. I didn't work for money. I am not rich. But success is not what other people think. What we think. So I'm very very successful. Don't compare yourself with other people with money etc. No. So how do you think of yourself as successful? I am very successful because I am peaceful. I am happy. I am content. Thank you. Okay thank you. All right on that winning note we'll talk about some strategies. Dr. Levin unfortunately had to step us step out for a convocation a little earlier than he thought he would have had to extend his apologies to everyone. But we'll talk a bit about strategies and then open it up to discussion to for folks to share individual experiences and also add to the pool of discussion that we're having. So for the purposes of this presentation we divided up strategies as individual interpersonal and as organizational. Oftentimes we do community as well but because we wanted to leave ample time we are limiting to these two for today. So strategies at the individual and interpersonal level. So they begin with recognition and education. To address something you have to become aware of it. Those that are committed against and by you. There should be education that leads to awareness. And forms like these are great opportunities to for individuals to learn about microaggressions. Then there's reflection and process. You know as physicians especially as psychiatrists this is what we do. It is our area of expertise reflecting and processing our interactions. The person who gets told you know that was an eloquent presentation who was left thinking would that same statement have been made to someone else who was perhaps not a person of color it was the case for her. So those are moments to reflect and process and doesn't always have to be with a provider a psychiatrist. Form your own communities where you could do that. And by processing and reflecting we can come up with strategies together to address reality test build resiliency and take time to process. Microaffirmations briefly the term was coined by Dr. Mary Rowe at the MIT Sloan School of Business. They are subtle or small acknowledgments of a person's value or accomplishments. They recognize the achievement of others. It entails taking a genuine professional interest in someone's life. And to a large extent the way I conceptualize microaffirmations as they're antidotes to microaggressions. While microaggressions exclude people, microaffirmations they bring people together. They include people. So briefly just talking about a strategy that is fairly straightforward. Upstander, bystander, upstander responsibility. Bystanders are individuals who witness an incident but are not necessarily compelled to speak about it. An upstander is a bystander who is who intercepts an incident. And an upstander is, there's multiple individuals in a room who one of them does notice that something that was said didn't ring right to them or notices an affective change on the other individual recipient's presence, then they'd be empowered to become, transition from being a bystander to an upstander. And upstanders should do their best to support and protect. And at an organizational level, there should be cultural change that allows for that. And bystander might be someone who takes note of the issue, but doesn't do anything about it. And they may have various reasons to do that, but that should also in a safe space be discussed and explored. So briefly talking about strategies at an organizational level. The first step of course is education. Educate about microaggressions in healthcare. And it's not a one-time event, it's a continuous journey towards sustained change. And there should be a culture of continuous learning that should be fostered at organizations. APA for instance, should be commended for committing to hosting a series of sessions on microaggressions. In various forms, we have spoken about this topic a number of times. And we are grateful that APA has provided this platform to talk about this topic that is incredibly relevant. And there should be awareness, promote awareness and education for decision makers, leaders, and everybody else. They should invest in educating decision makers, leaders, staff members, and there should be regular training sessions that should be mandated for staff to be completing. And then create structural changes to mitigate bias and toxicity. It's important to recognize that toxicity clusters, where there is a microaggression, there might be other things that are happening as well. It's not isolated incidents. So create changes that would help target these clusters. And this can be possibly had by, established by having a zero tolerance policy, implementing training, integrating DEI content into onboarding and professional developmental programs. There should also be supportive network of allies that invest in strong leadership. And they should commit their time to enriching conversations on this topic. And as Dr. Fonseca and I, both of us are recent graduates of the APA Diversity Leadership Fellowship. I mean, that's a fine example of an organizational strategy. The fellowships that this organization provides and presents, they are huge affirmations of our experiences and provide us the space to work on these topics of interest. They bring light to such issues and concerns and allow us the ability to bring in leaders in the field to talk with us as well. And then there's no change unless you have a way to measure it. So develop metrics that are outcome driven and be patient. Culture and cognitive change takes time. It will not happen overnight. So keep at it, be persistent. And tying back to the diagram that we started off by PASCO that we discussed earlier, creating an inclusive workspace that provides for social supports, keeps individuals from experiencing the heightened stress responses and engaging in adverse health behaviors is essential. It creates an environment where there are checks in place before the person engages in maladaptive health behaviors, has the overdrive of the HPA axis, there are measures in place to prevent the downstream consequence. Finally, I'd like to just end before our discussion by mentioning that a quote, famous quote by Gandhi, you must be the change you wish to see in the world. It's to empower everyone, you know, it's not, it's each one of us at the individual level that has to come up with our own strategies. Individuals together are parts of teams that shape up communities, that shape up organizations. Change really, it does start at the individual level. And the talk is dedicated to Chad Pierce. And with that, you know, we'd like to just open it up for some, these are our emails, but I wanted to, you know, have some time at least, I know we started late, to talk about experiences that individuals have had themselves or strategies that they would like to add on. And any, the more engagement that we have, the better. It's a space, safe space for us to learn from each other. Thank you. Hi, I'm Laura. I'm from Chicago. I'm a PGY-4, and I have a question that I just want your thoughts on. It's about reporting perceived race in a mental status exam or notes. I've heard arguments for and against it. I personally feel like I don't want to include it because I don't know if somebody in the future, one, is going to use that and bias future treatment. The second is there are people who are multiracial like myself, and when I see a note that describes me in a certain way that doesn't encompass my whole background, I get a little upset about that. So I just wanted to hear your thoughts on including that or not. I guess I'm being nominated to answer this. I don't include it in my note unless it's directly clinically relevant, like if a patient is coming in specifically because they have recently experienced a violent attack where they were targeted because of their race, or if they're presenting because of a specific, for example, hematologic condition that is present within their ethnic group. Otherwise, I would not include it in my note, but that is just the way I approach things, and I am by no means an authority on this. We're all learning, and we all have opportunities to do our part to make things better, but we're always also going to run the risk of screwing things up also consistently, and we're just called upon to try and do better. So for me, if I were to include something like that or not include something like that, I make it really clear to my patients early on that I am including pieces that are relevant to their identity, to their culture, and something that I say to all of my patients, one of the few perks of the Cures Act, I think, is I let them know as they're looking at my note in the patient portal, if they see something that they don't agree with, something that they think maybe needs to be taken out of the note, something that they think they would like to add to the note, to let me know, and I will make those changes, unless it's really crucial for their care and we want to include it in the note, and they have objections to that, then there are other ways to maybe leave a note for yourself in the chart without having that in the note where everyone else can see. So working around but working with the patient to figure out is kind of how I approach it. So this highlights a problem I'm having as a psychiatric geneticist as well as a passionate physician and clinician, and that is your X chromosome and your Y chromosome expose you to different risks as we understand the genes more and more. So to leave some of those things out of a note about you may make a difference as we understand more about the genetics and the risk genetics brings to you. Now, I'm a passionate, argue with my patients all the time. Genes is only about risk. It's not about destiny. There's a whole bunch of environmental factors. How could you be a psychiatrist and not think about the environmental factors? So how do we, I sometimes find myself having difficulty not making a microaggression by what I might include in a note, but that might be important for a clinician who picks up the case after me or sees it on the next ER visit or something like that. Do you see the conflict I'm talking about? What would be your suggestions on dealing with this? I think there's a few different layers to this one, right? Because you're mentioning information that may or may not be relevant to the reason for the patient's presentation. You're also mentioning genetics. And I don't know about you, but I don't run full genetic testing on all of my patients to figure out what chromosomes they may or may not have. So I don't like to make those assumptions either. And typically I do ask my patients how they identify. I work in a gender clinic, so it's very relevant for me to chart what sex they were assigned at birth, the gender that they identify as, the pronouns that they wish to use. And we're fortunate enough to have Epic where you can click in and have this organ inventory where you can mark what parts the patient does or does not have so that if they do come in, maybe they are unconscious that someone in a medical setting would kind of know what parts are there, what ways to kind of maybe perform the imaging or do the exam and intervene in a way that helps the patient for the patient. That's kind of how I approach it. And I would just like to add on to just briefly, really quickly to that, the DSM-5 TR that came out in 2023, and this was pointed out to us by Dr. Francis Liu. It took 50 years, but the term microaggressions is now in the DSM-5 from 1973 to 2023. It is in there and it is recognized as a social determinant of health and mental health. The experiences of race, bias, race and discrimination, bias and racial discrimination are incorporated. So if it is a factor that is considered notably affecting the individual's current presentation, by all means, I mean, you could include that. It's just about, it's individual specific and what the experience has been. I mean, for that reason, I mean, as a forensic psychiatrist, when I am doing evaluations and testifying, those pieces do come in important as mitigating pieces. So to take into consideration structural and social determinants of health and how they make an impact. I think there should be a dialogue among us about what to include in the medical record demographically and what we shouldn't include. I try to err on the side of asking my patient, you know, would you like me to say, there was a nice guy who came in and he said that he was mixed Filipino and European and his last name was Ghent. So I said, oh, you mean Belgian, or Belgian? He said, no, I'm German. That was important to him. So I wrote it in the record. Now I'm going to switch gears on you and tell you that there are trans patients where I work. I don't think it's anybody's business what their sexual orientation is with regards to their healthcare. Let me explain. I'll illustrate that by saying I had a patient who, for whatever reason, she disclosed that she had been abused in the prison. That's not uncommon. And I asked, you know, I asked her to tell me a little bit more about herself. And I told her, I'm not going to put it in the record that you're trans unless you want me to. Flip side of that is that I've been in team meetings where one of the nursing staff will cry out, will call out, oh, yeah, she's trans. And I get incensed. It's like, why did you have to say that? Why is that anybody's business? Thanks for sharing that. Again we want to document in a way that is centering the patient's best interests and in collaboration with the patient. So appreciate that. Sorry I'm very tall. Hi my name is Leonita. I'm a medical student at U-Dub and I guess the reason that out. Thank you. And I guess the reason why I bring that up is that I am a medical student at U-Dub. It's a regional campus and I am from San Francisco. So for background there was a point three percent chance that I would be accepted. I struggle with microaggressions regularly and I think on my surgery rotation I remember sharing with my attending that I'm from San Francisco. I go to U-Dub and she's like how did that happen. How did you get into U-Dub. And I started telling her about how I did a post back at UCSF. I worked in underserved populations and all this stuff and then she was like oh that makes sense. It makes sense why you got accepted to U-Dub. And I guess I remember for the duration of that surgery that lasted about like five hours. First week of my rotation there's six weeks total. It was something that stuck with me and still sticks with me today. And I guess I'm always wondering how do you navigate those situations when there's such a power differential. Like this is an attending, a really big name in this hospital and she's going to be evaluating me. How do I as a black woman but also as an MS3 speak up for myself when I know that I'm putting myself in a vulnerable situation. So any advice would be great. This question is a great question. Very frequently comes up and one of the best ways even when there are power dynamics as well, in a very gentle, comfortable way, just ask, I mean ultimately it comes down to what is the, I mean in this particular case the intent seems rather apparent, but asking the person why do you say that to me? Just having them reflect on it. And this was a strategy that was shared by President Stewart, Alpha Stewart, we presented on the topic and this was something she shared. Ask them to reflect on the process. And if why did you say that, how do you imagine that to be helpful? And if it doesn't go from there, hopefully the institution that you're at, there is some form of a community where you could bring this up, be it with your colleagues, with your colleagues at GME and hopefully it can be addressed. I'm sure that this is way easier said than done. So I would find your mentors, your sponsors, your allies. So folks who have maybe similar backgrounds, but also folks who don't, who are really in your corner. And once you find that group of people that you can trust, talking about things with them, sometimes these power differentials are so vast that it can be genuinely unsafe to have these conversations. You've worked for so long, you've worked so hard to get to this point, and so you say something and it upsets someone, there's a personality dynamic at play, they have all of this power, it's terrifying. So I think what can be really helpful is if you feel comfortable, if your ally, your mentor has a similar position of power, that they could potentially moderate a conversation in some ways. And that can be quite helpful. It's a method that I have had to use in the past. I have done the direct confrontation, but I think that requires a very, for the agitator or the aggressor, intentional or not, to have a very certain personality type where you know that they might be receptive. And that just isn't everyone. And I would just add, first of all, document. For example, send an email to yourself, dated, time stamped, just to, you know what happened. And tell a friend, find allyship, grow your own self-compassion, but also relatedness. Because disconnection is at the root of suffering. The opposite of suffering is belonging. So finding belonging, I think, is a, but these things add up over time. So yeah, thank you for sharing that very vulnerable moment. And yeah, I mean, I think many of us could relate to very similar things. So, yeah. Thank you. Dr. Boomer, you had a question? Okay, sorry about that. Okay. That's fine. All right. Well, thank you everyone. Thank you so much for coming and joining us. Thank you.

microaggressions

healthcare

racial biases

gender biases

sexual orientation

systemic biases

cultural humility

intersectionality

allyship

inclusive environments

zero-tolerance policies