OK. Let's go ahead and jump in. I just appreciate everyone's time and efforts to get up early and make it here and hopefully have some thought provoking discussion around this concept of professionalism. And I'm just I'm really honored and pleased we get to talk about this topic with you all. I think it's a really it's a core topic to our profession and I think really cuts across clinical context, educational context, community settings and so on, this idea of professionalism and what that means. I also have the pleasure of presenting today with some colleagues that we work together in kind of a national anti-racism curriculum group and I've had the pleasure of co-chairing this group with Dr. Walker and we also offer a number of live courses related to different topics on anti-racism and social justice and so it's a group effort. So we're going to have some information on our handouts that you'll get later on. So if you're interested in some of our materials, our curriculum, hiring some of our instructors, you can just go to the website that's on the that's on the handout. So my name is Dr. J. Corey Williams. I'm a child and adolescent psychiatrist. I'm a school based clinician. I'm based out of D.C. at Georgetown University and I'm going to let my colleagues introduce themselves. Hey, I'm Ashley Walker. I'm at the University of Oklahoma School of Community Medicine in Tulsa. I'm the psychiatry residency training director there. Hi everyone. My name is Kassaluchi Nendu. I'm a PGY2 currently and interested in university, mental health and just training wellness. So I'm really passionate about topics like this. Thank you. Okay, I'll turn it over to Dr. Walker. So just to go over our agenda, we're going to start with just a large group thought provoking question and brief discussion and then we're going to move into some some brief slides presented by Dr. Nendu and Dr. Williams and then the bulk of our session is actually going to be a case vignette that we're going to put you into some some breakout groups. Go over the vignette in your groups, talk about it and then come back at the end and then large group debrief with Dr. Ross. We don't anticipate that we're not we're not asking anyone to share personal stories or information today, but I think anytime that we are engaged in topics about anti-racism or other potentially fraud or uncomfortable topics, our group likes to start off with community agreements to help frame the space and make it both safe and brave for folks to speak about things like this. So these are the community agreements that we wanted to go over today and if anybody wants to add any, we can certainly do that as well. So first of all, starting practicing the gift of grace. So just knowing that we're all at different parts on our path, we're all coming into this space with different experiences and are all on a path of learning. When someone is speaking, we can start with an assumption that we all have good intentions while still knowing that intent is not the same as impact. So if somebody does say something that causes harm that you notice in yourself or that you notice is potentially causing harm to others, we hope that we can have the safety and courage to speak out and say something in this space to one another. Step up. Step up means that we want you to pay attention to your styles of communication and interaction. If you are a person who tends to hang back and just listen and not participate in the discussion, we hope that you step up into a place of more participation. If you tend to, because of your personality, your identities, positionality, tends to be somebody who dominates conversations and talks a lot during the conversation, we hope that you step up into a place of more listening so that you can also learn from your peers here. Listening with an intent to understand, I always like this one for myself, being open to the wisdom in each person's story, each piece of information that we're sharing up here or in the groups, and keep asking yourself, am I trying to be right or am I trying to do better? So it's always a good reminder to me. Respect and maintain confidentiality. Just like we said, we're not going to be asking anyone to share any personal stories, but if that does come up in our discussions, we hope that you maintain the confidentiality of anything people are sharing here, and we hope that through our dialogue, we will all reach greater levels of understanding of one another, but we also accept that there will be non-closure at the end. This is not the end of the conversation. This is just another step in all of our learning paths. Does anybody have any questions about those community agreements or any that anyone would like to add? And we're going to assume that if you stay in this room, that you are agreeing to these community agreements. Yes? Oops and ouch. Sorry. I went over that kind of quickly. So oops and ouch. Sorry. Thank you for bringing attention to that. So it just means that if somebody is harmed or potentially harmed by something that we might say, we hope that we can call that out or call that in to have a greater discussion about what was said, why it might be harmful, so that the group can keep going instead of leaving that person or persons who might be harmed to deal with that on their own. So this would be things like microaggressions or other potentially harmful comments that might come up. Does that help? Any other questions or ones anyone would like to add? Okay. All right. So we're going to have just a whole group discussion. You don't have to necessarily turn into pairs or anything, but just reflect on your own for a moment and then we'll take audience participation. Hopefully there will be a lot of thoughts on this. So I'm going to read it out loud. Imagine you're a director of a training program. It doesn't matter what, psychiatry, social work, et cetera, and you're reading letters of recommendation from prospective applicants. And one of the letters of recommendation describes the applicant as, quote, one of the most professional trainees the organization has ever seen. So in your mind, what do you imagine that this letter writer means and how would you define professionalism? So think for a moment and then we'll just take ideas from the audience of what you're imagining the writer means about this trainee. Anyone? Yes? Timeliness. So punctuality. So you're imagining someone that's always getting there on time. Good. What else? Yes? Compliance. Compliance with? With whatever people want them to be. With whatever people want them to be or do or, yes, yes. Grace under pressure. Grace under pressure. Can you give an example of that? So somebody who copes well under stressful situations and maintains their equanimity with all those involved, no matter what is going on, or how horrible it is, sure. Respectful communication. So communication is a big, broad core competency. Can you maybe give us some more details, like what would that mean, or what does respectful communication look like to you? Okay. Okay, yes, so I'm going to try to repeat everything. So especially in a military training program or military setting, they were saying respecting kind of the hierarchies related to the military. I also think in medicine, we have a lot of hierarchies, whether you're in the military or not. So maintaining those hierarchies and what's considered appropriate communication between the hierarchies. Can anyone think of what that might mean in a non-military setting, or I don't know if anyone else was thinking about, was anyone else thinking about communication in terms of professionalism? Maybe not. I know that that is, as a training director, one of the things that maybe the second, or one of the biggest things that will lead to improvement plans or corrective action plans for trainees is problems with professionalism and communication skills kind of falls under that. So yeah. Yes? Yeah, so does the person, so their attire, their appearance, are they dressing the way we think an adult should be as opposed to somebody wearing jeans? And who else was thinking about appearance? Yeah, can you give an example of maybe what you were thinking of? I just think how the person is dressed, the dress, the way many people in the organization dress and feel like this is appropriately presented to themselves. Yeah, so good. I like that. How do others in that organization dress? So what do we know about the organization from the letter writer here? Because they said they're one of the most professional trainees the organization has ever seen. Do we know what the people at that organization dress like and whether it's the same as our organization that we're accepting this person into? I don't know, right? Did you have something to add? Yeah Yeah, yeah, there's a lot of potential nuance there. I'm wondering, who here thinks ties are professional? Or their organization maybe considers ties professional? I see some nods. Is anyone at an organization where that's explicitly not expected? Yeah, I mean, yeah, I literally, one of my hospitals that I trained at as a resident for our child and adolescent, in their dress code, it said, women must wear pantyhose. And I was like, I am not wearing pantyhose. I am nine months pregnant, and I am not wearing pantyhose. Good, any other things? So we talked about attire, timeliness, respectful communication. Anything else that y'all were thinking of? Interactions with patients, that maybe would refer to their interaction with the patient. Yeah, so actually, your patient care, not just your communication with others, but your communication and interaction with patients, too. So all of that, we're thinking, falls under professionalism. So I'm getting the sense that when we asked this question, each of you kind of came to mind with a different image of what the most professional trainee this organization has ever seen looked like, and dressed like, and talked like, and all of those things, yes? OK, so that's just our framework for this talk. I'm going to pass it on to Dr. Anindu. All righty, y'all, can you hear me? As you all just demonstrated, when the topic of professionalism arises, the clouds of confusion descend, right? It's really individual, how we see it, and what we expect that person to be and do, and how they should look and appear, whatever it may be. And there seems to be no agreement on the definition of what the term professionalism actually means, right? And for centuries, organized medicine has attempted to articulate a unified conceptualization of medical professionalism. Despite its best effort, medical professionalism remains a fluid notion that has evolved over time to meet cultural, social, and political context of the moment. This fluidity privileges certain cultures and privileges certain identities. For instance, dating back to the time of Hippocrates, professionalism was focused on a virtue-based conception, which centers the internal habits of the heart, moral values, moral reasoning, and character development. Under this paradigm, doctors were viewed as moral agents who must put aside their self-interest to act in the best interest of their patient. This articulation of professionalism privileged and legitimized ancient Greek cultural ideas of morality and delegitimized non-Western healers, particularly healers from non-European cultures. Behavior-based professionalism has become the predominant paradigm in current practice of medicine. And with its focus on performance outcomes, behavior-based professionalism arose out of frustrations of the subjective measures of character and the apparent failures of trainees and physicians to assess their own, sorry, like to apply moral reasoning to their subsequent actions. Behavior-based concepts emphasize the assessment of absorbable behaviors. While this concept may seem more objective, conceptions of professionalism are differentially operationalized across multiple contexts in day-to-day practice use. Behavior-based professionalism is often used to encompass a broad and vague set of behaviors in addition to language, affect, styles of dress, timeliness, as mentioned, and unwritten codes of conduct. Professional identity formation has received considerable attention in recent years as a response to limitations of behavior-based framework. Under identity formation, learning is seen as a developmental process occurring at individual, psychological, and collective, sociological levels that socialize learners into thinking, feeling, and acting like a physician. But this begs the question on who describes how a physician should think, feel, and act, and from what cultural vantage. Great. Thank you. Thanks, Dr. Nandu. And I think the overarching point is that there's, you know, there are standards. The ACGME does have sort of professionalism standards as the AAMC. And I think what we're trying to argue here is that sort of despite these, that there are definitions, the ways in which professionalism is operationalized and applied is a sort of vague and sort of all-encompassing notion that touches on styles of dress, behavior, affect, the way we emote, the way people wear their hair, our relationships to authority and obedience. And what we want to argue, and thanks to sort of our scholars like Elijah Anderson and Issa Gray and others who have really been articulating the struggle for many BIPOC, black, indigenous, and folks of color, to the pressure that they feel to sort of assimilate into historically white spaces. And because professionalism is so all-encompassing and so vague, it sort of becomes this proxy for cultural norms in ways to sort of encode white cultural norms. And I think what we want to argue here is that because historically medicine has been predominantly white and predominantly male, these professionalism ideas that we have are based in whiteness and are ways to uphold structures of white supremacy. And I'm going to give you a few examples. This is one example that I want to just show you all a video. And we'll have some discussion on the video. This is an example by Dr. Princess Dinar, who you may have heard of. She's a med-peds physician at Tulane who is on an ongoing kind of legal dispute with her department around discrimination. And she helped develop this YouTube channel to help to show some of the experiences that she's had and other folks of color have had in that department that have to do with the sort of weaponization of professionalism, meaning professionalism as a means to suppress, repress, and assimilate black, indigenous, and folks of color. And this is one short example here. We'll have some discussion on it. So the physician here is meeting for her annual review with the chair of her department in this scene. Can everyone hear that? OK, wonderful. Committee has approved it. I feel we need to slow down. Professionalism? Slow down? What do you mean? Well, someone mentioned that your lecture on racism in medicine felt a bit aggressive. Can you give an example? What did I do that was aggressive? They didn't mention details. I believe it was more just the way your tone made them feel. So you personally decided to hold my promotion after it had been approved based on how one person feels? That is correct. And you cannot give me any examples of what was said or done? That is correct. Have you studied the promotions manual? Cover to cover. Where is this issue discussed? Dr. Jones, I'm really taken aback by your hostility right now. This tone is exactly why we need to hold your promotion. Dear Dr. Jones, we are writing to let you know that your promotion has been denied. We do not have a reason except for a professionalism concern. Even though the promotion committee has approved your promotion without mention of concern of professionalism, we wanted to let you know that we value you. Sincerely, Provost Masters. Yes, I hear some laughter. It is pretty absurd when you see it kind of in this format. But I think it speaks to a lot of the experience of folks of color in medicine and academia around the ways in which professionalism is brought to bear in such vague and nonspecific ways. So any reaction to that video? And say more. So, I mean, so if you don't have a reason. Right. The Promotions Committee has recommended it and then denied it without stating a reason why. Right. That's just not fair, equitable or anything. Right. There must be... And it shouldn't just be one reason. It has to be a series of... I know... Exactly. Of... You know, specified or unspecified lack of professionalism. Right. Right. Yeah, go ahead. I was going to say, well, they made a second example in the meeting. They're like, oh, this is another example of your hostility. Right. Somebody else. Right. So, it has to be something concrete, not just a feeling. If I say... Okay, microaggressions, for example. If I say, you did something and it made me feel this way. So, where do they... They say, well, I didn't need to make you feel that way. Why can't I do that same thing? Right. Right. Yeah, I mean, to your point, you know, you'd hope that... Oh, okay. You'd hope that the woman in the video had some avenue to, you know, have her concerns addressed. Because I think this is a serious issue. I mean, her promotion is being held up. And it sounds like, to kind of summarize, it was secondhand kind of information from someone who had received one of her talks and was uncomfortable. And I think it just speaks to kind of the dangerousness or the risk of professionalism as a construct. And it can become just sort of a proxy for people's feelings and people's discomfort. And when she tried to get some more specific feedback, that was received as being resistant or defensive. Right? So, again, like the way that she emoted or received the feedback in her relationship to authority was also sort of... Professionalism was used as a weapon sort of against her in this context. So, any other thoughts or reactions to this video? In the back there. I'm sorry. Yeah. This session is recorded, so we are going to ask if folks would like to speak to come up to one of the microphones. Sorry about that. Sorry. And I'm actually pretty short, so hopefully this is okay. My first reflection on this is there's a little bit of hypocrisy here. I think from a DEI perspective, a lot of these institutions try to recruit BIPOC people specifically for this reason, doing anti-racism education. But the minute that somebody brings up any kind of issues or does any directed teaching, there's a little bit of pushback. And then it's perceived as professionalism, but that's the reason why you're recruited there. Right. Yeah. Really great point. So, the point is that sometimes one of the main purposes of bringing in someone to your organization with lived experience of racism and sexism, ableism, and so on, is to have them do some education and some curriculum work. And it sounds like that was undermined here in a way that sort of just upholds a status quo. Right. So, great, great point. Any other reactions? I'll take one more if folks want to. There was a couple of other hands I saw. Maybe you just don't want to stand up to the mic. I was just... Another reflection that I had this time watching it was just encoded in what's professional is even what emotions you're allowed to feel or express, or who's allowed to feel or express them, right? Like, some people are allowed to express anger, and some people are not allowed to express anger in the organization. Right. Okay. So, I want to just transition us to talking about a study that we did that I think just illustrates some really important points about professionalism. So, I hope we've convinced you at this point that we have a problem with professionalism, and particularly in the way it's applied in its day-to-day use, especially as it pertains to black, indigenous, and people of color. And we wanted to kind of understand this a little bit better in terms of what were people's perceptions of professionalism, and then also their perceptions of their colleagues' levels of professionalism. And we did this study at University of Pennsylvania, and we were able to access the LISTSERVs for two major health systems within the UPenn systems, the VA and the Children's Hospital. And we were able to access the LISTSERVs for four different professional schools, so the School of Medicine, the School of Nursing, the Dental School, and the School of Social Policy. And we implemented the Diversity Engagement Survey. This is a survey, if y'all are unfamiliar, that's developed by the AAMC that's been sort of a validated workplace assessment tool. And we were particularly interested in the items related to professionalism. So it's about a 30 or so item questionnaire. And so what we did was we pulled out the items that were specifically related to professionalism. And we were able to survey about 18,000 people across the institution, and we had about 3,500 respondents. And so we did a close examination of three items in the survey in particular. So the first one being, I have considered changing jobs due to inappropriate, disruptive, or unprofessional behavior by a coworker or supervisor. That was the first item. The second item we pulled out was, I value institutional initiatives, policies, and or educational resources related to professional behavior in the workplace. And then the third item of interest was, my institution supports a culture of professionalism. So the first one being, I've considered changing jobs due to unprofessionalism. Number two, I really value professionalism in the workplace. And number three, your perceptions around how the institution supports a culture of professionalism. And so there's a lot of data here, and I just want to highlight just a few findings here. And I'm happy to sort of go do more of a deep dive if folks are interested afterwards. But for the scope of this presentation, we were interested in kind of the historically marginalized identities in medicine. So we analyzed the data based on wanting to take a close look at women, women compared to men, or female identifying folks compared to male folks, LGBTQ plus identifying folks versus heterosexual identifying folks. And we were interested in underrepresented folks, so non-Hispanic black versus non-Hispanic white. And for the purposes of this survey, for statistical power, we had to group some non-white identities together into kind of a sort of other category as well. We also looked at non-Hispanic Asian versus non-Hispanic white in the analysis. And there were some other analyses as well. And then there was sort of a professional role analysis as well. But I want to highlight just a couple of things that really jumped out at us in the analysis. So female identifying folks in particular, when they were compared to their male colleagues, were much more likely to say that they have considered changing jobs due to unprofessional behavior from colleagues, much more likely to say they value professionalism, and much more likely to say that they are much less likely to agree with the statement that their institution supports professionalism. And these trends were also mirrored in the LGBTQ plus folks. So again, considerations around changing jobs and feeling like the institution doesn't support a culture of professionalism. And the same was true for the first item when looking at non-Hispanic other races or ethnicities when compared to non-Hispanic white. And then the same was true for non-Hispanic black when compared to non-Hispanic white colleagues. And then there was this interesting finding around staff versus faculty. So really, I think just to kind of summarize, your kind of social identities really made a difference in terms of your perceptions around your colleagues' professional behavior and the extent to which you value professionalism and the extent to which professionalism has changed your career decision-making. And then what we did was there was sort of a follow-up campaign to this study where we sent out a sort of a qualitative open-ended question, which we called, tell us your story of inclusion, where essentially in an open-ended way, we asked folks to send us vignettes or narratives around experiences they've had with inclusion or professionalism. And what we did was we did a qualitative thematic analysis on some of the narratives that we got when we asked people, just tell us your story, tell us about things that have happened to you in regards to professionalism. And some of the vignettes that we got were really kind of striking and jarring. And I just want to highlight a couple. So this was a student respondent in this first quote here at the top, and the student was telling a story about a clinical experience, and the student writes, the physician grabbed my right forearm and pulled it towards the patient. The physician asked the patient, does it, meaning the patient's color of diarrhea, look like her arm or is it lighter? The physician chuckled and said, your skin is a perfect color for this job. So in this moment, the student's skin color was sort of compared to the color of the patient's feces or stool. So really hard to read every time I read that. Another vignette I wanted to highlight, because I think it's illustrative, someone wrote, every time the minority group resident came late to rounds, even if he or she was accompanying a patient to a test or it was documented in writing, it didn't matter if a white resident came late to rounds or conferences. Their lateness was never documented. So there was two themes that we felt like were highlighted in these examples, which is greater infringements on professional boundaries in the form of racism and sexism and ableism and microaggressions and so on. And then at the same time, being subject to greater scrutiny over their professional boundaries. So in this case, the minority resident was having their tardiness or alleged tardiness documented, which was not true of the white residents, at least in this person's experience. So again, having greater infringements on your boundaries, but also being subject to greater scrutiny. This was a third theme that we felt like really jumped out at us when we analyzed the narratives. So people talked about this a lot around having to feel like they had to fit in. And people use the word fit in their narratives a lot. So a couple examples. Someone said, I don't feel welcome here. Even in the LMSA or SNMA organizations, I felt the pressure to be whiter and not allowed to feel comfortable in my own skin language culture. I don't feel included, but instead feel pressure to become white. And again, as we've been alluding to, this could mean a lot. This could mean speech patterns. This could be pressure to be hyper-punctual or to be hyper-obedient to authority and so on. So this concept of fit could mean a lot of different things. But there was a salient theme around assimilation and pressure to conform in the responses that we analyzed. This was a Muslim-identifying survey respondent who wrote, I was asked to cover my colleagues during Christmas and Jewish high holidays, and I was happy to do so. In later years, I've been asked for time off during my own religious holidays. And this has been met with polite ignorance or an unconscious devaluation of non-Judeo-Christian traditions. So here, a really insidious example of not having your holidays acknowledged with the same level of concern and responsiveness to other folks compared to other white Christian holidays. So just making the point, we also did a follow-up study on wellness. And folks' perceived discrimination was correlated with symptoms of depression. And this is well-documented in the literature around a range of mental health outcomes and medical outcomes related to experiences of discrimination. So I think, really, the point here is that we're really talking about retention when we're talking about professionalism and workplace climate and culture and also wellness. So I think what's at stake here is when we're talking about being more inclusive and diverse in our definitions and applications of professionalism, this is how we actually get people to stay in our profession. This is how we recruit. And this is how we create a more diverse and inclusive environment in the workplace around this concept of professionalism and keep our trainees and employees and faculty and staff healthy in the workplace as well. So I'm going to transition us, and we're going to get into a small group vignette. But I just want to leave you all with these take-home points, which is we really need to revisit definition, standards, and applications of professionalism, given that they've originated and have been cultivated with a really narrow, homogenizing, predominantly white-dominant cultural lens. And this has done a lot of harm and is continuing to do a lot of harm in how we use professionalism. And because it's sort of vague, all-encompassing notion, Brene Brown has this really great quote around assimilation being the opposite of inclusion and how professionalism is like this flexible sword. Because it means so many different things, it can be sort of weaponized and brought to bear to repress, to discriminate in so many different kinds of areas. So it becomes like this flexible sword that can arise just to sort of map on to someone else's discomfort. And I think that ends up being predominantly white discomfort in many cases. And I think the main takeaway here for me is that we have to maintain a healthy skepticism to when professionalism is discussed, when our trainees and other staff are sort of cited for professionalism, when someone's professional behavior is sort of put into question, we have to unpack what exactly are we talking about and in what context. Because I think if we just sort of jump to conclusions, I think we risk reproducing some of these structures of white supremacy that we're talking about. Let me pause there. Any questions? So the question is, so what do we do? Do we just sort of throw out the concept of professionalism? And I'm actually interested in the group. Does anyone have any thoughts on that? Given that we know that professionalism has been disproportionately weaponized against women, against BIPOC folks, what do we now do? Do we just not use a concept of professionalism? Do we change it? Do we try to include some different definitions? Do folks have ideas about that? Yeah, thanks for that. So I heard kind of emphasizing being treated with respect, emphasizing sort of having good character, character traits. And yeah, and I appreciate the comments. Anyone else want to comment on that? What do we do with the concept of professionalism? Do we just throw it away? Go ahead. I guess I would like to think that these sort of things need to be revisited, but also to be revisited, but also a process needs to be put in place. So a lot of people feel like the Constitution, for example, is this document that shouldn't change and shouldn't be adapted. And unfortunately, we're in this place where it's really hard to make any kind of change in a positive direction. But I think codes of conduct, professionalism, these sort of things need to be revisited as other voices come into the fold, the main fold, which has been largely exclusive for a long time. Yeah, appreciate those comments. I want to have a fuller discussion towards the end about that. Because I think after we sort of unpack the vignette, I think folks are going to have some more thoughts around professionalism and what we might do with the concept. So let me put a pin in this discussion, and we'll revisit it after our vignettes. Thank you so much. So I was going to add that. So we're going to transition into our small groups. Dr. Anindu has volunteered to pass out the handout. So the front half of here is getting part A. The back both sides of the room is getting part B, I believe. And then the front side over here is getting part C. So we really just want you to get into maybe twos or threes to discuss the vignette. So you've got an intro on each person's handout as an intro, and then your part, part A, B, or C, and then a final piece. So we're going to spend about the next 25 minutes or so for you in twos or threes to go over all of that, intro, part A, B, or C, and the final part, and discuss. And if you have time to discuss what we just had gotten to before the breakout, if you had time to discuss what should we do about this concept of professionalism, feel free to discuss that as well. And then we'll come back at the last 25 minutes or so to have a big group discussion. Does that make sense to everyone? Or any questions? OK, all right. Thank you. If you're OK to use a mic, please use the mic. If for some reason you don't want your voice we'll have somebody else repeat. Thank you. Like many others in this room who may be different in terms of your ethnicity, your hair, what you wear, very triggering. This has been my story from medical school all the way up to being a resident. It's really hard to kind of look at because oftentimes this is the narrative. I can just give a brief kind of example. And in my medical school I happened to wear a, it was like a head wrap. And it's very common to kind of wear a head wrap. And I had on really nice earrings and makeup. And I was told, well, my head wrap was unprofessional. And then had to kind of navigate that conversation with my leadership. And so this is all too common for women who look like me, unfortunately. And so it's often the conversation is, and what I try to kind of say up front is, here I am. This is who I am. How can we support people who look like me? And I like to have those conversations before starting programs. Because it's, you know, my sister who's also a physician, we have this conversation. And we always say, it's not if it's going to come. It's when it's going to come. And you have to set yourself up to be able to have kind of a professional kind of dialogue about when this does happen. Thank you. I'm sorry. Thank you. Other reactions to some of the dynamics in this particular vignette? Whether from people who were talking about that initially or are just scanning it now? I just wanted to jump in real quick and just say, I just appreciate the sort of supporting the sort of authenticity of the vignette. I think a lot of folks reading this vignette, especially folks of color, have told us that, yeah, this resonates. Because this is a systemic pattern. And this was a real case that we sort of had to change some details to protect identities and such. But we've basically written up a case as it happened. So folks should feel, you know, you should feel something about what happened here. I can speak to that. And I can say, I worked with Corey. And I'm like, Corey, this sounds like stuff that happened, you know, all the time. So I mean, I think a lot of us have been the felt like the trainee in this experience. I think some of us who are attendings felt like an attending in this experience where someone has come to us and said this. And I think our group's initial responses were multifold. Like one, we did think that race and or gender played a role in the fact that I think a black female resident came to a white male attending concerned about a racial slur and really was dismissed. And it's interesting because she then went to the medical director the next day, which we actually thought was the appropriate chain of command. And then he complained that it wasn't the appropriate chain of command, right? I think it also led to a discussion in our group about how, you know, as psychiatrists, to some degree, we're the experts about talking about really uncomfortable things, except this, right? We can talk about suicide. No one wants to do that. We can do that. We can't talk about this. And even, you know, and I actually think about like the ACAP, you know, milestones for trainees. And some of it is, how do you feel in the face of uncertainty? And so we thought, you know, there's an attending here who maybe doesn't know what to do. We're giving him the benefit of the doubt. He doesn't know what to do in this situation. He feels uncomfortable, so he essentially dismisses it, as opposed to saying, hey, that sucks. I don't know what to do in this situation, but, you know, and that at least, like, room to kind of support the trainee going forward. I think I also, as a child psychiatrist, was concerned about, if he's ignoring this, the resident is bringing up, like, how much is he actually even understanding the patient's experience? Because I bet whatever racial slur is happening is a part of why they're admitted to this inpatient unit as is. And again, just thinking about, what are the structures in place to kind of help the resident, but also the attending and the medical director deal with these issues? Yeah, I really appreciate that formulation. So identifying, you have an attending who's probably uncomfortable having this conversation, who probably lacks the skills and the experience and probably has never been trained to know how to navigate this. And the system is protecting him. It's protecting and prioritizing his white fragility over the needs and concerns of the patients and the trainees in the space. It's ugly. It's really ugly. And then when she appropriately blows the whistle, the system just leans all into that. Yeah. So I live in Atlanta. I work in Atlanta, Georgia. And I was working then as a resident in community mental health mostly for African-Americans, mostly. And this patient came with a Confederate flag. And I'm not originally, I mean, I'm originally from Syria. So when I saw him, I was really shocked. And I told him, you know, I think this is offensive. So right away, I brought it up to him. He's adult, by the way. And so he told me, and I'm going to use that word, he said, go fuck yourself. And he reported me to the attending. The attending came and he said, this is none of your business. You don't talk to him about this issue. And by the way, you're not even American. And you should be tolerant of people's point of view. I got the blame for this. Wow. Wow. Oh my gosh. So you're trying to do the right thing, calling out, trying to protect the space for the other individuals in the clinic. You end up getting flagged as being unprofessional and then separately attacked for your identity. Exactly. Yeah. So I was unprofessional, intolerant, and on top of that, you're not even American. So why are you bringing up this issue? There's that separate dynamic of just the medical hierarchy itself and the way those power dynamics play out. And you end up getting bullied for being the junior member of the team. Was it a male attending? Male. Yeah, and so you also have gender dynamics added on to that as well. Male, Caucasian. Wow. And all the patients were with him African-Americans. So I was trying to, you know. Yeah. It's really hard to get traction at an individual level on these problems because they're system-wide problems. And unless you have institutional policy, you can't gain any traction. Yeah. Thank you for sharing that. Yeah, one more comment and then we'll switch to the next vignette. I'm really struck by this space of like whose voice needs to be speaking up and you could say well maybe if somebody who identified more directly spoke up that that would be more powerful. But that's also asking for the minority tax that we're putting the people who are being systematically discriminated against to speak up and fundamentally structural racism is a white person problem. So the problem with this vignette is that the leadership of the hospital doesn't care. And if you have a room of old white men talking about this situation they do not think it's as important as the individuals who were involved in the story feel that it was. And yeah I can't be right. So it needs to be everybody it needs to be the white folks speaking up against this too. Thank you all. What a rich conversation. Okay second vignette group B. Oh geez story Corey already alluded to. These are based in reality. So so this is one where there is a black patient on whom the nursing staff is very quick to call the police and a white patient who actually assaults and attending for whom they do not call the police. And then when they're called out on that they say that the resident was combative and accusative and they had professionalism concerns. So thoughts or reactions from the folks who were dealing with B. Except a heavy sigh as the first response. Actually, we're a room full of psychiatrists. We can tolerate uncomfortable silence. Indefinitely. Just kidding. So we talked about several different dynamics at play here. First being the idea of racism. And kind of structural racism in the scenario both for the patient and also for the resident. The fact that like a white patient similarly actually did like a violent response like on the unit. Like an assault actually. I think they kicked the person. Yeah, they kicked the attending. And just got a comment of don't worry about it. She doesn't mean it. But an African-American patient just standing close to the unit elevator is being perceived as trying to elope. Was a structural racism issue. Kind of like a cultural competency problem as well probably. And then from the resident's perspective, just generally being kind of devalued. One, probably because of age. And the dynamics between being like an intern talking to a senior nurse. And also being an intern talking to an attending. And then even just this comment of like you were basically, let's see, being combative and accusative. And we talked about how the perception of being considered racist for a nurse or an attending on this unit can have like significant implications on the situation. Can you elaborate a little? I'm having a little trouble hearing you. So you can be a little closer to the mic. But there were a couple things you said. The last bit about the nursing dynamics. Yeah. So like most of the people in my small group were all residents. But all similarly have had issues in which senior nurses like devalued our perspectives on patient care. And have made comments of like you're just a resident or you're just an intern. So from a team dynamic, not necessarily being considered an equal member of the team. And then specifically like with this case, the fact that the resident is also like African-American, it seems like that perspective was also just equally devalued. So devalued, yeah, because of their identity. Corey knows I'm a big fan of organizational behavior frameworks. And so thinking about groups and intergroup dynamics. And this one especially around safety is so hard. Because the nursing staff and the mental health workers are often the ones who are on the front lines of violence. And are personally in danger more than the physicians are. Often, not always. And so these can often become these lightning rods for bigger issues. You also, you started by talking about the structural racism. There are many facets of it here. I'm curious which ones were striking you as most prominent. So, and I guess maybe just like taking a step back and actually thinking of just structural competency. So the fact that these are female nurses and a male patient. Probably has some dynamic in regards to like using restraints. And seclusion for this particular patient. And then the other aspect of it being an African-American male. Which potentially could be seen as like a flight risk. Just by being African-American. Potentially had large implications on this case. And or being just perceived as being aggressive or violent or dangerous in a way that the white patients wouldn't be. So as a black man, I guess he's a child, adolescent. He's more likely to be perceived that way. Yeah. That's all I had. Thank you. Other thoughts? I'm not sure how well people in the back could hear. The comment was around criminalization and the carceral system in the U.S. and the tendency to criminalize black men and then also the failing to appreciate the impact, the differential impact of calling police onto the unit and how that may impact the black patients. I wanted to build on that, too, because I think there's a connection between the story that we heard initially around the cultural sensibility that especially black folks have around the Confederate flag, right? That's a symbol of being in danger for black folks. So that cultural sensibility or connotation that black folks have. And then here, this residence bringing to bear a cultural sensitivity, meaning the black children's sort of connection or relationship to the police. And in both scenarios, when those cultural sensitivities are sort of brought up, they're both suppressed or they're both sort of quieted. So I thought that there was a connection there in those stories, the ways in which sort of professionalism in these cases are used to sort of silence and repress different cultural perspectives or sensibilities on a certain situation. As you're talking, I can't help think, what would they have done if somebody showed up wearing a swastika? That would not go. That would not happen, right? But the Confederate flag is okay, even though it is similarly a direct symbol of oppression. Just to expand that to the other systems, right? We know that young black boys are often given ODD diagnosis when really they have ADHD, which is a less stigmatized and kind of a more easily treatable diagnosis. We know this happens in school where, again, black kids are more often suspended, say, than white kids. This is true. And I have a lot of kind of not to speak for black folk. I'm obviously not black, but right. Even speaking out, you become the angry black person who's saying something. You could be talking, and I'm very loud, you could be talking quieter than I am, but that's who you become by saying anything, because it's perpetuated in a fear of the black body, which is also just seen in so much of society, media, film, et cetera. One more comment from the back, and then we'll get to the third vignette. First these were really great vignettes, so I really appreciate it. The thing that I think for me came together was the fact that the perpetuation of the whole, the system, that the white attendings are going to understand this patient or think they understand the patient, so they say, well, the white girl, she never had any intention of hurting anybody, whereas with the black young male, they see him as somebody who potentially is going to be violent. And so that resident probably in reaching out for safety, she's going to talk to her family about this. Her system's not safe to discuss this, so that kind of perpetuates this whole idea of why do we even bother going into medicine? Yeah. And how can we possibly support trainees through what we know is an extreme, under the best of circumstances, residency training is extremely difficult. And now we're saying you're going to be disproportionately exposed to these traumatic experiences, and we're not going to support you through it. And if you complain about it when it happens, we're going to actually label you as being unprofessional and punish you for it. Yeah, thank you. Yeah, thank you. I'd just kind of like to reiterate what I saw as well, as this is just a glaring example. Well, first of all, by the way, I'm wearing shorts today, so I don't know if that's professional. I see a lot of suits, a lot of college shirts. I haven't seen a whole lot of shorts, so just putting that out there. It's okay. I got you. So, yeah, I think this is just a glaring example of what we're seeing in a whole lot of other different contexts, which people are pointing out. That's a judicial system, educational system, psychiatric system, psychological system, education, all of these other different facets. I thought this was a glaring example of that. I did struggle, though, with the tie to the professionalism kind of down at the bottom. I felt like this was kind of an example of something else where professionalism was kind of being used as, well, this is a professionalism issue, but this isn't really a professionalism issue, even though that was the excuse being used. Oh, it wasn't even remotely a professionalism issue. Right. Yeah. Yeah. But for the talk, I think I kind of struggled with that, at least, just for me. Yeah, no, that's fair. The point is exactly that, that we're using this word anytime somebody behaves in a manner that is inconsistent with the governing rules of the system. Right. The system defaults to a white-normed perspective, and anybody who's bucking that is going to be labeled as unprofessional. Yes. I totally see that. What I learned in this discussion, which was a wonderful group over here, that this is a real difficult topic, as was mentioned earlier. There's a lot of stuff involved in this, but I don't even know who I am. I don't even know how to identify myself. There was some other people in the group that don't know how to identify themselves. I say, what do you like to be called? How do you identify yourself? For example, African American versus black, or Hispanic versus Mexican, or native indigenous versus Indian. I work in a native clinic, so those are kind of the statistics that I was looking for on that one study earlier. I think that's one component here. I noticed the doctor, I apologize, doctor, I forgot your name, sitting out. Williams. Williams used black earlier, and then in other connotations, African American. I'm kind of confused on where I'm at in a lot of this, and where other people are in this as well, if some of that makes sense. I'm not sure. Yes. Thank you for sharing. Yes. I think the quick answer would be we're all on a journey. Yes. Yes, totally. We're all on a journey. We're all at our own place on the journey, and we keep working, and we do the best we can, and we study, and we learn, and we make mistakes, and we learn from those, and we try to work together as a team to move forward. We can get into the details afterwards if it's useful, but I think that would be the big picture answer to that. If we're looking for the right answer to anything, it doesn't exist. I do want to make sure Group C had another of a doozy of a resident who's really keyed in and focused on social determinants of health and their impact, and the attending wants nothing to do with it, and gets upset that they're wasting their time on all of this useless stuff. And so then when the resident presents because they're feeling anxious, so they're wearing headphones, and they're dressing in a particular way, they are accused of being disengaged and inappropriate and unprofessional and unkempt. Anyone want to respond to that? Well, I'll speak to some of it. Somebody else may also want to say something. One of the things that we zeroed in on is the fact that the attending seemed to feel she had given an order in a way. She told the resident to do something rather than, and it is appropriate, we acknowledge for an attending to want to guide a resident, but we also noted that the attending was not open at all to learn anything. You know, it might be a conversation about why are you including these things? Is it really slowing the resident down? Is it really problematic or has the attending just, you know, given this order? And once the resident felt attacked in this way and started defending herself with headphones and she's accused of being disengaged, you know, there was a power dynamic in terms of the attending and the resident. There's a cultural, you know, being told that she was unkempt because she was wearing a head wrap. There were all these things wrapped in that a dialogue may have prevented. Why are you including these things? This is how you might do it. And also the norm, it was brought up that the norm of you have so much time, you know, we're working our way toward the 15 minute, you know, med review so that you could do so. Productivity, you know, this is the most important thing. These things are not relevant because I think one of the things the vignette said was that this information is irrelevant and distracting, which seems ridiculous given the type of information that it was. I don't know if anybody else wants to. I'm so glad you just honed right in on that bit of like, this is about the power dynamics. It's about the obedience and the idea that this resident isn't doing exactly what the attending asks them to because at surface it is so manifestly absurd that you have a psychiatrist saying that this part of history is not relevant. It's so absurd that it defies any possible conversation. So this is really about that power dynamic and yeah, please. So speaking to the power dynamic as well as the SDOH piece, I think this is where I see that those of us who are no longer in training who are now in positions of power have the ability to be mentors for folks and be able to be the ones to stand up so that when this resident encounters this situation with an attending that is less than ideal that they have somebody that they can come to so that those of us who are now perhaps at more of an equal level can try to address these things within departments or within systems in which we work and where some of the work that is happening around SDOH kind of stuff can be brought up as actually the social history is only going to get more and more important because the way that we're looking at funding and supporting medical and psychiatric care is through funding some of these things. I'm in North Carolina and in our Medicaid program, we have a new pilot called the Healthy Opportunities Program where Medicaid dollars are being used specifically for food and housing and a bunch of other kind of non-medical things since we know that 80% of health is based on not stuff that happens in the healthcare system. And so I expect, unfortunately, that these situations are going to continue to happen for our residents, for our other attendings, for other people, and I think this is where we all bear the responsibility, especially those of us who are coming from a place of privilege to be able to kind of push some of this when folks are coming up against systems in which they're kind of hitting this. You're unprofessional. Yeah. For sure. Thank you. I mean, our model of Western psychiatry, if we're going to do a 15-minute med visit and pretend that that's effective is so manifestly absurd. It's just not consistent with any data or any understanding of this because you're talking about that, right? Like there's the Berwick article, the moral determinants of health, if you haven't read it, it's like really good, like right in there. And it's a good segue. We have, by my count, probably two and a half minutes left. I'm curious if anyone has any overall thoughts or reflections on the session today and or thoughts about how we move forward most constructively. Well, I mean, just such a strong point. Thank you so much. I mean, I think that one of the unifying themes of each bit of the vignette was just sort of a lack of self-critique and self-reflection from the folks who were in charge. So I just want to leave us, you know, I know we're up against the clock and such a rich discussion. I feel like we could do this for hours. I want to leave you with a few take-home points because I think it speaks to the sort of core question of what do we do with professionalism and some things to think about after you leave. So we have to keep in mind professionalism is a vague, fluid, and historical notion that has been largely based on adherence to white, cis, heteronormative, dominant cultural values of speech, affect, behaviors, and dress. We sort of begin there. And then we have to understand that professionalism citations have been historically weaponized against by POC folks to surveil, repress, and assimilate, as well as protect white privilege. And then the third point that I really hope you all take away is that we need to maintain a healthy skepticism towards professionalism citations when professionalism comes up in our different contexts and seek to obtain more social and cultural diversity, inclusion, and context for whenever these issues come up and sort of unpack our own discomfort when we feel like someone is being unprofessional and start with ourselves and understanding like what is this about? Why do I think this is unprofessional? Is this more about me or is it about what's actually happening? The last thing I'll do is just plug our group. So the National Anti-Racism in Medicine Curriculum Coalition is this national group of anti-racist educators that are developing curricula like this, which you accessed today, and we regularly give this talk, this presentation for other institutions. So if you're interested in bringing this session to your institution or your site, please just go to the website and there's a contact tab there and you can just send us an email. It's namcc.net. It's also at the bottom of your handout. So if you want to follow up with us, the easiest way would just be to go to the website and those messages go straight to us. I'll leave it up. Yeah. So don't, no rush there. But can you just join me in just clapping it up for all of you and just appreciate the thoughts. Thank you.

professionalism

diversity

BIPOC

systemic privilege

anti-racism

institutional bias

cultural competency

inclusivity

power imbalance

workforce diversity