Hello, welcome to our webinar, APA webinar, Returning Race to the Clinical Dialogue, Maximizing Use of Ethno-Racial Demographics in Clinical Care. This activity is funded by a partnership between the Striving for Excellence Series, which was made possible by a grant from SAMHSA. And please note that the contents do not reflect the views of SAMHSA. They reflect the views of the presenter. This activity is also, qualifies for one AMA PRA Category 1 credit. And just a few housekeeping tips, in order to download the handouts on your desktop, you can use the handouts area of the attendee control panel. If you are in the instant join viewer, click the page symbol to display the handouts area. I'll leave this up just for a second. In order to participate in the desktop, use the questions area of the attendee control panel and in the instant join webinar view, click the question mark symbol to display the questions area as indicated in the diagrams. I have no financial relationships or conflicts of interest to report. I am Dr. Constance Dunlap. I am a psychiatrist in Washington, D.C., where I live and work. I have a private practice of psychiatry and psychoanalysis. My clinical appointment is in the Department of Psychiatry and Behavioral Sciences at GW, where I am a clinical professor of psychiatry. I'm also a deputy representative of the Area 3 Council of the APA Assembly. And I mention that later because it has some relevance to this topic. So let's set the stage. I want to launch right into a vignette, which was provided courtesy of Dr. Shana Popkin, who is a resident at GW, and this is the case of Jane. Jane is a 72-year-old with a history of hypertension. She's a 72-year-old woman with a history of hypertension, diabetes type 2, asthma, osteoarthritis, and generalized anxiety disorder, who was admitted to the hospital with shortness of breath and found to be COVID-19 positive. And this is a vignette that is a composite of cases that were seen early in the pandemic. Jane's vitals were stable. Her O2 sat was 96% on 4 liters nasal cannula. But 25 minutes later, a rapid response was called. And it was called by telemetry because the patient had desaturated after pulling off her oxygen. And this was the reason that psychiatry intervened. What I would like to do is illustrate, use this case to illustrate how race can be included and the times when race can actually not be included, and that's actually helpful. What I would like to do is go over the learning objectives. By the end of the presentation, it is hoped that the participants will be familiar with contemporary use of demographics, such as race, ethnicity, and other variables denoting difference. We'll know the pros and cons of including ethno-racial identifying data and the chief complaint in history of present illness and elsewhere in a write-up and even in a verbal presentation. We'll also have the skill to make use of ethno-racial demographics in a manner that deepens clinical understanding and fosters better clinical care. And what we mean by that is in a manner that hopefully does not reinforce biases and in a manner that doesn't allow biases to interfere with treatment. Now, why are we discussing this today? So let me just step back and I want to thank Ebony Harris, who is in the Office of Education at the APA. Ebony reached out to me and asked if I would do a presentation for this series, this partnership between the APA and Morehouse. And as we talked about the possible topics, I thought about my experience during the pandemic. And this quote from Dr. Acosta, an article by Acosta and Ackerman Barger, entitled Breaking the Silence, Time to Talk About Race and Racism, really captures where we are in this country and in medical education. And as they observed, recent events in the U.S. have catalyzed the need for all educators to begin paying attention to and discovering ways to dialogue about race. And this title includes us, educators in the health professions. And generally in our field, if you are in attending, you're educating in a clinical setting, if you're a supervisor, you're providing education. But the point is that we are educators as also physicians and mental health professionals. And so one thing that I noticed over the last 18 months of the pandemic, and especially during the first phase of the pandemic, I noticed how race, during Grand Rounds and also in other settings, I noticed how race was not included at times in clinical presentations. And because the pandemic allowed us more of an opportunity to participate in more virtual webinars and seminars, I, like many others, have had the opportunity to participate in a number of teaching activities. And so one thing that I've noticed, and this is after the murder of George Floyd, this is after the over 2,000 global protests of the killing of George Floyd, I noticed that in presentations, students and trainees had started to omit identifying information about patients. And it was a little disconcerting, but I continued to pay attention. And what I noticed is that there was also some discussion about how this was intended to discourage bias. There are two schools of thought about this, and one is that you should include it up front, and one is that it should not be included, and in fact, there's even a third that says it should be included, but it shouldn't be included later, maybe under social history. But the point is, what I would like you to walk away with today is some understanding of when to include it, actually want to acknowledge that there are times when it's okay to not include it, but also want you to feel more comfortable including it. And so this is our outline. One thing that I would like to say is that this topic has actually gotten a lot of attention because medical students and residents are expecting and demanding changes. And the COVID-19 pandemic has profoundly reaffirmed the need for health equity, which is what these students and residents are advocating for. What I would also like to do is talk about some of the historical antecedents, and I'll start with the recent, this is the 21st century, we're 21 years into it. And so I want to talk about some of the highlights of the 21st century, and then I want to connect that to the longstanding antecedents, which are referred to as 400 years, and usually that refers to 400 years of blacks being in this country. The next section will include the development of a toolkit and some information about theory and technique for that. And this also include exposure to language, it's important to have a glossary of terms in order to hear and be heard. And then some remedies for personal professional growth, and there are quite a number of resources at the end. And at the very conclusion, there will be an opportunity for Q&A. Now, this is, there are a number of articles, and by the way, you'll notice that most of my references are coming from the medical school, because the medical schools, actually from the students, and some is from the residents, but it's really the students that have taken the lead on this. And this is an article from the New England Journal of Medicine, and it is authored by a number of collaborators, and some of the names you'll see repeatedly. And this article really summarizes the data that shows that medical schools are propagating physician bias because of the way that race is represented. And this is an excerpt from the very beginning of this article, which says very clearly that race is not a biological category, based on innate differences that produce unequal health outcomes. However, it is a social category that reflects the impact of unequal social experiences on health. And so what the collaborators notice in their research is that, for example, they categorize the different domains. And for example, they notice that words, there was a problem with semantics, using words that are imprecise, that are not biologic labels, that conflate race and ancestry, are problematic. For example, even the use of the word Caucasian is inaccurate because Caucasian is not, it's not an identity. It's an identity that is connected to the Caucasus mountains. And so, for example, and we'll see later that instead of referring to someone simply as white, it is helpful to also when meeting with a patient and at an appropriate time, and I usually do this in the intake, I ask about a patient's ethnic identity because everyone has an ethnic identity. There are some people who would describe a Nigerian patient, and this may be a Nigerian, first generation Nigerian as African-American. And as opposed to taking the time to note that this is a patient who has closer connections to Nigeria, and even to say this is a Nigerian-American would be more appropriate. There is a problem with teaching students that black patients have higher rates of disorders, which in fact are not accurate at times. And then even when the incidence is pointed out, it's not connected to some of the social determinants of health and mental health. There's a tendency to, in terms of race-based diagnostic bias, there's a tendency and the testing tends to reinforce this, you know, priming students to think that sickle cell disease is a disease that only affects black people because what happens here is that black people then are not screened for other diseases like Tay-Sachs, for example, and also without teaching the history that sickle cell disease is a disease that is common in populations who were at risk for malaria. There's also the tendency to pathologize race, like in this case, the students were shown a slide that showed 13 types of brain tumors in black patients, and saying that the incidence was higher among blacks when 10 of the tumors occurred more frequently in whites. And so in some of the race-based clinical guidelines, and there are guidelines, and then there are actually practices that occur in the clinic, and, you know, one of the most striking ones is tending to use, the example they cite here is using first-line antihypertensive drugs in blacks, but without offering blacks other alternatives, and a really good example is tending to use high doses of antipsychotics in blacks when it's known that blacks do not handle high doses of antipsychotics. And so here are some of the recommendations that this group made, and one was to standardize language used to describe race and ethnicity. And so, for example, and this will be available to you, but instead of using imprecise language like Asian or African American, you know, there's a suggestion that you identify, you know, Asian, okay, well, you know, Asian is really generic, and so you can be more curious about the also ethnic background. And I've already mentioned avoiding using terms like Caucasian. So there are two primary clinical applications and two paradigms. One is the omission of race and demographics, and the other is the commission, and what I would like for you to do as we go through some of the clinical vignettes that are interspersed in this presentation, I want you to pay attention to your own personal internal reactions as we walk through them, and ultimately the question is going to be, which is going to provide more informed, effective care? And so let's go back to the vignette of Jane. This is the same patient. So now this is later on rounds. The patient was resting in bed, drowsy and soft restraints. Overnight she became agitated, ran out of her room trying to get home. The pharmacology that was used was Haldol, Lorazepam, and she was also placed in soft restraints as was stated above, and collateral information included the fact that Jane's husband died from COVID-19 in the ICU the day before. And here were some of the ethical dilemmas. How do we tell Jane? When do we tell Jane, and will she even understand? And so let me share with you my reaction upon hearing this case, this seminar, and let me also acknowledge that this was one of the best resident seminars, just one of the best grand rounds, and this happened to be presented by a resident, but it's one of the best grand rounds I had heard. However, I noticed at the beginning without race and ethnicity being mentioned, I was a little puzzled and wondered when it was going to come, and as it turns out, it did not come. And what that allowed me and others to do was to focus on really the medicine, and I say this not excluding the importance of any social determinants of mental health, but what Dr. Popkin conveyed to us is that this was a presentation that was designed to help psychiatrists understand the medicine and all the different systems and how the organ systems and how the body was affected from head to toe. And by not including race, we were able to focus on the systems. Now this is not something that we ordinarily see, because the reality is that identity does have an impact, but this being able to take this approach allowed us to really focus on the medicine, and that has some implications for treatment. So now, let me just go back. And so while I was initially thrown off by not having race mentioned somewhere along the way, what this also prompted me to think about is the fact that when race is not included, so just think about this vignette, when race is not included, traditionally, because of the way society is organized, and frankly, because of structural racism, we have assumed that the person is white, and the media has reinforced that, I mean, just, you know, all of our structures. And so traditionally, if the race was not mentioned, it was assumed the patient was white, and if the patient was BIPOC or another racial group, that would be identified. And so it causes us to make assumptions. And the reality is that we can't make assumptions. There are times when I'm presenting a patient, and I have found myself just aware that there are moments when I realize someone may be assuming the patient is Black because I'm Black, and I'm aware that where the patient is not Black. But the point is that we also make assumptions based on who's presenting. And the point here is that we can't really assume anything. Ultimately, if it's relevant, we need to ask about it. And again, we'll get to that. So in terms of talking about this, the first thing that we want to think about is communication. And communication comes down to speaking the same language. It also comes down to hearing, listening, and being heard. And I just want to go through some definitions that are relevant. And by the way, I realize that some of the people who have tuned into this, there's probably a range of participants, because there are students who, and some people, clinicians who are very versed in this material, and so some of this is going to be very elementary. But at the same time, we have on the other end of the spectrum, people who have not taken the time to pay attention to this developing nomenclature, and also who have not taken the time to look at the social issues that are actually propelling the changes that we are making and need to make. And so I want to go through some basic definitions. And this information comes primarily from a 2005 article by Smedley and Smedley, who are anthropologists, who have focused on the way that race is misused and the way that it is written about in society. And so here's a definition. Race refers to skin color, hair texture, nose width, and lip thickness. They have remained major markers of racial identity in the United States. So the use of these criteria continues to be arbitrary, given the ranges of physical variations in U.S. racial populations. And one thing that I recommend in this article, the reference is included at the end, there's a section of references, and one of the things that the Smedleys do is that they trace the emergence of race, and this goes back to the 1700s, you know, when there was the initial effort to categorize whites, really Europeans, indigenous people, and Africans, enslaved Africans who had arrived, who had been brought to the U.S. And race used to be just a generic description in, you know, in discussion in England. But coincidentally, as Europeans were focused on rationalizing their need for liberty and rights and, you know, equity, and their separation from England, they use race to justify their subjugation and dehumanization of Africans. And so this is the place where race emerged. And by the way, Dr. Harrison has done a webinar for this series, and there's a link at the end. And I refer you to that webinar, because it traces this history, going back from the 1800s up into contemporary times. I also have included a reference to the OHSU inclusive language guide, which is shown here. And this is, it's a very nice guide that has, it goes beyond race and ethnicity, and it includes a number of terms, terms that are specific terms for specific groups. It also addresses immigration status, language proficiency, ableism. So it's actually a very, very nice resource. Okay. I also want to introduce this word into this discussion, caste. And this is a word that has been around for years, and originally it referred to the hereditary classes of Hindu society, distinguished by relative degrees of ritual purity or pollution and of social status. The author, Isabel Wilkerson, in her most recent book, Caste, has suggested that using caste is another way for us to think about our hierarchy in this country. And she suggests that we have a caste system. At the top is the dominant caste, also known as ruling majority, favorite upper caste or white and everything in between. And also including the subordinate caste, which is, refers to African American or black. She also refers to an original caste, which refers to indigenous peoples, and another caste, which is marginalized people, which refers to women of any race or minorities of any kind. And so it is, we're starting to think about this as another way of understanding the racial and ethnic, really power hierarchy in this country. BIPOC refers to black, indigenous, and people of color. And it is a term that you will see used. And it's used, however, when it is, when you're referring to, to groups that fall outside of this. One can also say black, indigenous, Hispanic, Asian, and other people of color is just a broader descriptor. I'm going to mention colorism here, because this is known in the black communities, also known in other communities, other ethnic communities, and other communities of color. It's a form of prejudice or discrimination in which people are treated differently based on the social meanings attached to skin color. And I mentioned this because this is something that is present, it's relevant. You will see if you follow popular culture, you'll see that, or you will notice that Lin Emanuel Miranda's movie, The Heights, there was some criticism because he did not include, he and the director did not include darker skin Afro Latinos. And the concern there is that the reason was colorism. I like for clinicians to think of this, and especially really everyone to be open to this, because sometimes in a same race dyad, black person, black clinician, black patient, it will come up. And one of the ways it may come up is that you may have, and it can go both ways. You may have a dark skinned person who is struggling with that because of discrimination. And sometimes we'll talk about that, especially if the therapist is lighter in coloring. Because sometimes they talk about it in the displacement and you also have, there have been and are people who feel uncomfortable with having less coloring because they are uncomfortable about some of the privileges that people assume that they experienced. And so the point is you just want to be open to it and listen to see if it's something that may be relevant for the patient. Racialization is the act of giving racial character to someone or something. It's a process of categorizing, marginalizing, or regarding according to race and act or instance of racializing. And this is a term that we are starting to use that are saying that someone is a minority. For example, I might say the person is a racialized person or racialized from a racialized group. Now culture, this is really interesting because as the Smedleys point out, the anthropologists, they talk about how culture isn't fixed. They do not treat culture as being part of anything innately biological. And they also point out that groups are not, individual groups are not born with propensities for any particular culture. What is most important is that, as they point out, culture trains, the people that are not born with any particular culture or culture trains or language only with the capacity to acquire and to create culture. And that would explain why anyone, any child that's put in another culture can easily adapt to that culture. And they point out that the human capacity for language is the one, is what enables individuals to transmit culture trains from one person or group to another. Now ethnicity and culture are related phenomena, as the Smedleys point out, but they bear no intrinsic connection to human biological variations. Ethnicity refers to clusters of people who have common cultural traits that distinguish them from other people. For example, people who share a common language, geographic locale, or place of origin, religion, sense of history, traditions, values, beliefs, food habits, and so forth are perceived and view themselves as constituting an ethnic group. And what I want to say about ethnicity, the Smedleys point out that physical characteristics are never, should never be used to determine one's ethnicity. Because an ethnic group can have, can have people that have very different phenotypes. Ethnocentrism is a belief in one's own superiority, belief in the superiority of one's own culture and lifestyle. And it leads, it can lead to ethnic conflict. It's not always the case. And if you look out, look throughout history, you will see that people, and this was Africans as well, did trade with different countries and the, and the different ethno, ethnic groups were accepted and lived peacefully. But ethnocentric beliefs and attitudes can and do change sometimes rapidly. And what, and what they do when they do change sometimes, especially because of projection, so you can have two groups living next to each other, let's say Croatians and the Serbs, and or, or I think of the Ethiopians and Eritreans, the English and the Irish, you can have two groups living, you know, adjacent to each other and just peacefully, peacefully coexisting. But something will happen to cause one group, and it can actually go both ways to really project their unwanted qualities onto the other group. And what is striking is that ethnic, ethnocentric conflict tends to occur among people who do live adjacent to each other. I want to say something about assimilation and this, you know, this is a word that we don't pay a lot of attention to, but I want to mention assimilation because it really does help to differentiate between race and ethnicity. And so the Smitleys point out that as they recognize that race and racism are not mere ethnocentric dislike and distrust of the other, assimilation refers to the process of receiving new facts or responding to new situations in conformity with what is already available to consciousness. And so the reason assimilation became so important in this country is that for Europeans and white-appearing immigrants arriving in this country, the message was, you will become like us whether you want to or not. In other words, assimilation was required. However, for those from the lower castes, the low status racial groups, the message was, and this is because of coloring, no matter, and other features, no matter how much like us you are, you will remain apart. So therefore ethnicity was recognized as plastic and transmissible, but race conveyed the notion of differences that could not be transcended. So there are some, these are just some highlights, some terms, and these are terms that I think that, you know, as clinicians, each of us should be familiar with. This is a reference to the Aspen Institute site, and they have 11 terms that you should know in order to understand structural racism. And they, you know, they define structural racism, they define diversity. So that's a good resource. I'm not going to go to that right now. And so these are just two references, the Aspen Institute and the OHSU Inclusive Language Guide, and there are others, but here are two that are at your fingertips. Now, in terms of understanding why this has been a concern and why, you know, the statement from Acosta and his group at the beginning of the presentation is so important, the question is, why are students and trainees, residents and trainees concerned about this? Well, here is a slide summarizing events just from the 21st century. And I just went back to 2001, September 11th attacks, we just celebrated the 20th anniversary. And then, by the way, black and brown people and other marginalized people, and that includes marginalized whites, have been killed by the police from since the beginning of the country. Also, we talked about how law enforcement's origins occurred during slavery, as slave patrols were developed. But if you just take a look at this outline, you'll see 2001, September 11, then starting with 2012, Trayvon Martin is murdered, 2013, the Black Lives Matter movement is founded. Then you have Michael Brown, the National Medical Association issues a position statement on police use of force. And then just in 2020, you have Ahmaud Arbery, just before the pandemic was declared on March 11, there's the killing of Breonna Taylor, then there's the killing of George Floyd, then their position statements from APSA, the AMA, APA, and many other organizations. And with this came a new and renewed interest in diversity, equity, inclusion, and anti-racism. And then just coming up to this year, the murder of George Floyd was convicted on June 25th. So this is the quote from Ta-Nehisi Coates, he says, but race is the child of racism, not the father. And what he is pointing out there is that, as he said, and he goes on, and the process of naming the people has never been a matter of genealogy and physiognomy, so much as one of hierarchy. And that's what race is about. And so it is about hierarchy. So I want to connect this, but let me just pause here, because students are demanding our attention, and they are demanding that we make changes in medical education and training, in curricula, in organizations to address a white supremacy culture, which is connected to the structural racism that we continue to refer to. And so one of the things that was revealed last year during the protest is that many people don't know the history, and so are puzzled, you know, even by the protests. And people with privilege have also been able to not particularly pay attention to this. However, the students have. And so let me just go to the next slide. Because this history from the last, from the 21st century, it's at the end of 400 years of history. And when you hear the expression 400 years, what we talk about is 400 years of Blacks being in this country. And here's just an outline, starting with slavery. And by the way, when I did this slide, I realized after the fact that I had omitted the American Civil War, which is from 1861 to 1865, you know, quite an oversight. But I have it here highlighted because, and the reason that it's important to highlight it is because this is a wound that our country has experienced, and we have never grieved it. We've never mourned. And as you know, in order to mourn in a healthy way, we have to acknowledge something. We have to acknowledge the loss so that we're able to accept our losses, do our bargaining, but essentially arrive at a point of acceptance. And in some ways, in a very profound way, as a country, we have not done that. And so I also have here summarized the, from 1870, the 15th Amendment was granted, giving men the right to vote. And then there was Reconstruction, Black Codes, Jim Crow, and some other important dates, including the Brown v. Board of Education. And then you see there's the Civil Rights Act, Voting Rights Act, formation of Black Psychiatrists of America in 1969, then mass incarceration. And then in 1992, rioting after officers were acquitted and beating a Rodney King. This is a lot of history. And what I suggest is that you consider this book by Professor Carol Anderson from Emory. It's called White Rage. And for those who are maybe thrown off by that title, please consider the message. What Professor Anderson has done is she has, in five simple chapters, she has given us the history of what happened with slavery, what happened with Reconstruction, the emergence of the Black Codes and Jim Crow, the effort to dismantle the Brown v. Board of Education, and her last chapter is How to Unelect a Black President. And what she is talking about here is that, you know, in the past, people have talked about Blacks having rage and us wanting to tear things down. But what she points out is that it is the rage of whites that have resulted and the resistance to acknowledging that our country has moved on and is trying to move on. And so then this is just the other part of that history. So I want to say something about the role of protest. And this doctrine of qualified immunity, which protects state and local officials, including law enforcement officers, from individual liability unless the official violated a clearly established constitutional right, is what is known as qualified immunity. And I put a slide in because this is what has led to the protests, which were really organized in a very different way in 2013 by the founders of the Black Lives Movement. And there have been other people, including athletes, entertainers around the globe who have embraced this as a mission, including Colin Kaepernick. And this is a list of the people who have been killed by police. It is a long list. The names are listed in alphabetical order by the first name. And so I just ask you to go and take a look at this if you're interested. The names would not fit on a slide for sure. So now I start with that because it is to help you to understand how students and residents have organized. And so what students and residents have done is that they form, some have formed white coats for black lives. And this is an organization that is, has organized to protest police violence, but they've gone beyond that. They also are holding medical schools and training programs responsible for dealing with structural racism and making changes. So it's not just about the protests and it's not just about law enforcement. It's about social justice in society. And so one of the things that they have done is by shedding light on what has been happening with law enforcement, which also is connected to the way that girls and boys, and my talk here clearly has been focused more on black and brown because for about an hour, you know, there's only so much that we can do. But hopefully this will help you to just at least organize your thinking and give you some basic information because much of what is said here can be extrapolated to other groups who have been marginalized. And so one of the problems with the way that we blacks are portrayed in society is that when you see these images repeatedly, what happens is it leads to dehumanization. And so what happens is over time, you end up with girls and boys also being dehumanized. And one of the ways that dehumanization starts is with adultification. And what that refers to is creating narratives around girls and boys that, you know, attributes to them violent behavior, it could attribute their just behavior that may be considered ordinary behavior, ordinary youthful, even acting out behavior. It is considered intentional and malicious instead of it being the result of an immature decision-making, which is a key characteristic of childhood. And this is a study from Epstein and others, which is done at Georgetown University Law School. I want to go to the next slide. And I'm going to take the moment to play this video. And because as W.B. Du Bois wrote in the Souls of Black Folk, which was published in 1903, he talked about this concept of double consciousness. And what he talked about, he was talking about Blacks coming out of slavery during Reconstruction and really grappling with who they were and how they're seen. And then as we also move into society, moving into integration, you know, still being required to look at ourselves through the eyes of others and at the same time balancing our positive view. So in other words, maintaining a sense of self while also managing others' projections, if you will, and others' assumptions, others' biases. I want to just play this video because I think that it really illustrates what this looks, what this can look like. 🎵🎵🎵 🎵🎵🎵 I played that video because it is the experience that children have. It's an experience that starts in childhood. And I think that is particularly concerning for black boys, but it's not limited to black boys. I mean, this is what it feels like when one is considered the other and one is treated in such a way. And so the residents and students have actually been very active and they have been protesting. And so here the slide says protest is dangerous, and I believe it's dangerous because it upsets the status quo. And what happens is the reason that protest comes about is because the students have actually won. You think about this age group, this cohort, they're younger. They are generally growing up in a more diverse society. They're exposed. Social media is also accelerating their exposure and they're connected with people throughout the world. And even when I think about some of the trainees that are coming from places that are mostly white, that don't have very much of a diverse population, they still have more exposure for a variety of reasons. And so they're coming in and they have more knowledge, but they also tend to be open. And by the way, I'm making a generic statement because I know that there are also political views, excuse me, that are relevant here as well. But the point is, it's the imbalance in knowledge and comfort and personal exposure that is that is causing a problem. So in some ways, the students, residents and fellows who are ideally who should know more than a faculty are coming in knowing more than a faculty. They also the ones who are shedding light on the health disparities and inequities and generally are more open to challenging them. And so they want to move from the way that it was to doing something different. And they also are more aware of the troubling interactions around difference that occur. And, you know, depending on how it's handled, you know, some will speak up. But there's also a fear that there will be repercussions if they speak up. But the point is that also, as we've seen from the recent census, the demographics are rapidly changing. And then we have the diversity, equity, inclusion and anti-racism efforts, also known as DEIB, diversity, equity, inclusion and belonging. And so this is creating a need to do something different. This is a quote from Dr. Martin Luther King, and this is from a letter he wrote from Birmingham jail. And he says that we who engage in nonviolent direct action are not the creators of tension. We merely bring to the surface the hidden tension that is already alive, bring it out in the open where it can be seen and dealt with. And this is what the students and trainees are trying to do. And the reason that this must be done is because the imbalance in knowledge creates discomfort, primarily in the supervisor. Which then leads, if that affects the management or if it affects the supervision, that can lead to compromised care. So it also can lead to the trainee not getting the theory and technique that they need, especially when you're talking about psychotherapy. And so here's a Venn diagram to give you an idea of what that can look like and what I have represented in terms of the size of these bubbles. You know, in this center, you have shared awareness and knowledge and, you know, each person, you know, bring something, you know, to the table. But when the faculty member or supervisor has relatively less knowledge, you can see the imbalance and it puts a lot of pressure on the student or trainee. And sometimes the patient and the student, you know, can try to manage. I've actually spoken to people who have, you know, very wisely gone elsewhere to get the supervision that they needed because they recognize that they could not get it from the person who was assigned to them. And so I'm going to just go over a couple, a few vignettes to illustrate how information can be brought into a session. So in this vignette, this is the first psychodynamic supervisory meeting. In the first meeting, resident Dr. A provides the HPI and chief complaint and recent material from their last session. He says that the patient, a middle aged woman, is from one of the Caribbean islands. I ask her racial and ethnic identity. He does not know. Sorry for the typos here. I suggest that he ask. For example, I offered that I refer to myself as black. And I'm comfortable with African American as well. But prior to my offering that Dr. A, who is white, mentioned that he did not think that she would refer to herself as black because that sounded negative. And in that case, he was, you know, revealing a bias that he has. And by my just matter of factly letting him know how I refer to myself, I'm modeling for him that not everyone has internalized, you know, those distortions. This is in the middle phase of supervision. An Asian American resident is presenting material from her work with a young white man from the southwest of the U.S. This session occurs two weeks after the massacre of eight Asians in Atlanta, Georgia. The resident is Asian, as I've said. I ask if the patient had mentioned the attacks or expressed curiosity about the resident's well-being. The resident had not felt comfortable bringing racial and ethnic identity into the consultation room. The patient, usually preoccupied with her own personal problems, was able to shift her attention and volunteer that she had been concerned and thought of the resident. But because the resident had not been comfortable, just even, you know, and by the way, in doing supervision, we don't automatically just focus on race. You know, there is a rule that the patient's material is what is central, and especially for patients dealing with a crisis or patients dealing with something more acute or, you know, patients dealing with medication. We address those things. And then we address these other things that may not be so salient. So I want to go back to the vignette. And here I've changed the vignette. This is the vignette from the beginning, Dr. Popkin's vignette. And in this case, the patient is John, and a code strong is called. And, you know, what that means in GW is that there is a need for help with restraining the patient. And so on rounds, this patient. So now this is a man. And I'm going to say now, well, let me just say this is a man, John. He was resting in bed, drowsy and soft restraints. But overnight he became agitated and ran out of his room trying to get home. And the pharmacology that was considered was Haldol, lorazepam, and he was placed in soft restraints. Collateral information is John's wife died from COVID in the ICU yesterday. And there are these ethical dilemmas. How do we tell him? When do we tell him? And will he understand? Now, at this point, it's important to not it's important to acknowledge race here. I mean, for example, you have and this is a black man and who also is faced with being restrained. We need to be aware of how he might feel as we would be aware of any patient. But we need to be aware of also who is there, who is interacting. Is he the only black? Are there others? In other words, what do we do to make him comfortable? And also in terms of using Haldol, this is when we must know the identity of the patient. In other words, when we're now talking about medications and not just for this patient, because there is a tendency to reach for higher doses of Haldol. It's true for every patient. But I have to say, because we know that blacks have received disproportionately higher doses, we must really be mindful. And so in this case, we find out that John's wife died. So I want to expand this. This is not just about race. But this is when we also want to know about a patient's spiritual beliefs. Let's say John is Jewish. And by the way, you know, this is a pseudonym. But what are the religious beliefs? You know, what are the concerns about burial? So do you see all of these identified information really has bearing on how we understand the patient and also how we understand the patient's support and also how we understand their coping mechanisms and resources? Here's another vignette, and I think we're close on time. In early January after the January 6th insurrection, a junior resident is presenting material from his recent session with the patient. I asked how the patient is doing. At this point, the election was undecided. I'm anxious. Most people are anxious. The resident indicated that the patient, a black woman, did not talk about politics. And it doesn't matter what the race of the resident is here. The point here is that here's where we can say, and if you just assume that most black people were concerned and, you know, were concerned also about voting, being excluded from voting, you could imagine that this black woman actually might have some concerns about the election. But take political beliefs out of this. This is a time in our country when here's a situation that affects each of us. Everyone is anxious. And so I believe that in this case, the resident did not ask about it because of his own political beliefs, and he wanted to stay away from that. And there is a way to express curiosity just by asking, how are you doing? How are you doing with the election? How are you doing? Are you watching the news? But also, generally, people will bring things up. But when we find that people don't bring things up that are obvious, we have to ask, are they not bringing them up because they're sensing that we are not comfortable? And then, of course, you want the supervisor to be able to help facilitate this. And this applies to reactions to other global protests and other events. And so how do we cope? We cope in the way that we cope with everything else. There are unhealthy coping, denial, avoidance, silence, disavowal, splitting, projection, and projective identification. And by the way, Dr. Kim Leary has written about how silence is one of the most common enactments in treatment. This is in psychoanalysis and psychodynamic therapy, but it's also an enactment that occurs in supervision. And so we must get beyond our silence and find a way to have a conversation. And one of the ways that we do that is by having some healthy coping mechanisms like curiosity, one having cultural humility. In other words, we are not expected to know about every culture. But one of the things that we do know is that our curiosity about others is what helps us to understand and learn. Also having some frustration tolerance about what we don't know. And then also being able to mourn some of the beliefs that we have that have prevented us from being more curious and having more humility. And so the tools start with awareness, facilitated by information, strengthened by exposure. And there's a bidirectional learning with the resident. It's reinforced with practice. And we acknowledge that it's an imperfect process. Another thing I suggest is considering a self-assessment. And I like this slide says you don't have to see the whole staircase, just take the first step. A self-assessment, which you can do the privacy of your office or home or whatever, is something that will help you to see where you might want to focus. And if that's too threatening, I suggest that you read an article. Pick up a book. But these are the salient insights and acknowledging the need. Acknowledge if you have fragility and fragility is really refers to Robert DeAngelo's book, Why Fragility, refers to the discomfort, the uneasiness that we develop when we are confronted with, for example, the notion of white supremacy, the notion of privilege being a concept, the notion that, you know, we might have benefited. But it causes people to become defensive. It also causes people to want to, you know, avoid whatever material they are confronting. Again, curiosity helps with that. Collecting data, you know, those information, developing some critical thinking, surrendering of perfectionism, because this is definitely a trial by error. And if your intention is good, that's going to make the difference. And we're going to have missteps. It's OK. It's how we recover from those. And by the way, patients are very forgiving. Trainees are as well. This is an example of a personal assessment from the Anti-Defamation League. And let's see remedies. So here's another thing I would ask you to consider. You know, why are you doing this? And there has to be some emotional component. And it can be that you have empathy. It can be that you recognize you have some fragility. It can be that you recognize you have some shame. But tap into the emotional reason. I'd like to give the example of Robin D'Angelo, who talked about in one of her interviews, she talked about being white in San Francisco and but being poor. And it was being poor that helped her to identify with other people who are marginalized. I have been curious about why does this woman get it? Why is it that this woman? How is it that she's been able to do this work? That was her entree into connecting. Beverly Stout, in a recent article, has talked about black rage. And what she's talked about here is the constructive, really the sublimation that blacks have used because of their rage to propel them to become constructive. And I think about people who are protesting. It's not just limited to blacks, but people who are protesting are trying to find a way to mobilize their anger, their frustration. It also keeps them away from feeling helpless. I suggest you consider personal psychotherapy or psychoanalysis. And of course, you can always do consultation, peer consultation, traditional supervision. And the goal here is to create more of a balance. And it's not going to always be equal, but it's going to vacillate. But the goal is for the student or trainee to feel that they have a partner with the faculty and supervisor. And the patient is then more effectively supported in his or her process. And then just the last thing I will say, this is about developing wisdom. And in order to develop wisdom, we have to own a shared history. So I'm going to bring up critical race theory here. And I'm not going to get into the definition just because of time. But what I do want to say here is that there's a recent backlash. This is being used to undermine our efforts to deal with structural racism. And it is driven by it's motivated by resistance to change. And it's an impediment to education and growth. And it undermines health equity. And I believe that as clinicians, we don't we're not in a position to say we we can take a side on this. This is not about a side. If we want to be effective as clinicians, we need to know what the information is. We need to know what the history is so that we can also put ourselves in a better position to mourn. And the other reason that we want to do that is that white coats for black lives, they have flipped the script on grading. And so they are issuing what's called a racial justice report card. And what they are doing. And this is a pilot with. Oh, must be a number of medical schools. And GW is one Harvard and most no one received an A. And they indicate that they are evaluating institutions based on their underrepresented medical student representation. The faculty representation, the recognition, the recruitment, the anti-racist training and curriculum, discrimination reporting. The underrepresented medical medicine, medical grading disparities and campus policing. They really are looking at whether or not campus policing is overly utilized or whether or not the other resources. And so they are looking at us. And by the way, these are the kinds of report cards that are going to determine where a student or trainee might consider trying to match. And so this is, I think, the end. Here are some resources. There are a number of self assessments. Their list of articles. These are the other resources. And by the way, I want to bring attention to the APA Learning Center that is under the Division of Education. This webinar by Dr. Hairston is can be found there. And this is a list of books. Organized by year. Some videos. And I also want to thank Dr. Vinson, the chair committee chair of the striving for excellence program. Leon Lewis, the director of scientific programs in the APA Division of Education. And Miss Ebony Harris, senior instructional designer to Emma Shana Popkin, Miss Dr. Shana Popkin. And I'd like to close with this quote from James Baldwin. Not everything that is faced can be changed, but nothing can be changed until it is faced. Thank you.

race and ethnicity

clinical care

examples

demographic data

historical context

cultural humility

diverse populations

protest

self-assessment

resources