This presentation is being recorded, so if you have any questions and want to say anything, please do so, but use the mic. And if you would like us to repeat the question, that is fine too. This is meant to be an interactive exercise, not to make you feel like an imposter in that way, interactive, but to think about the ways in which we've experienced this phenomenon, either in ourselves, or our friends, or colleagues, or heard about it, and think about it in a way that feels personal, or it can be relatable, and that's what the interactive exercise is gonna be like. So it's a little bit of didactic style, and a little more of like a interactive exercise style. With that, I want to start the presentation today. This is not our first time doing this talk, so we've had this talk before, but it was focused on the imposter phenomenon in women. And I think the more we've researched this topic, and had discussions and debates about this whole phenomenon, we've realized it's really not specific to gender, or age, or race, or any particular variable that you could think about, but it's an experience that's very personal and internal, and so we wanted to bring this back in a way that's more relatable without any of those identifiers. So I'm Tanuja Gandhi. I am a child and forensic trained psychiatrist. I practice at Brown in Rhode Island. I'm also actively involved in the APA, and in another organization called the Indo-American Psychiatric Association. I do not have any relevant financial disclosures for this morning. In terms of learning objectives, there's an awkward position to the computer. In terms of learning objectives, we would like to enhance understanding about the challenges faced by trainees in practicing psychiatrists in the context of feeling like an imposter in professional environments, to create a safe space for discussion about this phenomenon, a critical but often uncomfortable discussion to have, to examine and discuss factors contributing to the feeling for trainees in practicing psychiatrists. So I have my wonderful co-presenter who's also a dear friend and a very senior colleague in terms of experience, both professionally and in the APA, joining me, Dr. Cheryl Wills. The presentation itself is gonna be divided in two parts to give you a frame for the session. I'll be doing a lot more of the background and think about individual factors and ways in which you can address this phenomenon, and then we'll move on to talking about structural and other factors which will be addressed in detail by my colleague, Dr. Wills. So, you know, for some of you, this might be familiar, but when I read about it, it changed how I thought about things about myself. When asked how she felt to be seen as a symbol of hope, she said, I still have a little bit of an imposter syndrome. It never goes away that you're actually listening to me. It doesn't go away, that feeling that you shouldn't take me seriously. What do I know? I share that with you because we all have doubts in our abilities about our power and what that power is. If I'm giving people hope, then that is a responsibility. So I have to make sure that I am accountable. I think you might be familiar with this person that I'm talking about, and there's an interview where she talks about this experience. So I'm trying, for the live recording, I'm trying to stream a YouTube video of the interview, which I think is taking a minute to load. So while it's loading, this is an interview of Michelle Obama, you can actually find it online on YouTube, there are a few of them, but this one particularly strikes a chord, where she talks about this feeling of being an imposter, and that this feeling actually goes with you everywhere, because there are structures in place since you're a child that tells you, oh, you cannot do this, because, you know, you can't go this far, because, and there's always this variable and a limit attached, be it by gender, be it by race, be it by culture, and she talks about how she took it upon herself to address those variables or to challenge her every time that limit was set, and move on, but also acknowledges that this feeling can be very common, even with people who are very successful, very influential, and very powerful, but still feel like an imposter in their own settings. Well, I think, yep, I'm just going to move on, but please do see this video on YouTube if you have the time. So the term imposter syndrome was coined in 1978 by two American psychologists, Pauline Clancy and Suzanne Imes, and they published this wonderful article that talks about this phenomenon as a syndrome at that time, and they initially described it with a focus on accomplished successful women, gradually became clear that it's a phenomenon and not limited to gender, and the Merriam-Webster's Dictionary itself has a definition for what feeling like an imposter is like. It is an internal feeling of self-doubt, not belonging to a particular group that can lead to the fear of being disclosed as a fraud or being an imposter, and hence the term. It manifests in many different ways. People could feel like an imposter and credit other people or luck for their success, have a fear of being seen as a failure, overworking to meet and exceed expectations or overcompensate for that feeling, feeling unworthy of attention or affection, downplaying accomplishments and holding back from reaching attainable goals. It can affect people regardless of age, gender, level of success you've seen, and you've heard me repeat this many times today because that is really true. Common within the medical profession, and again, across sub-specialties, it impacts all levels of medical training, that means someone can feel like an imposter as a student or as an attending. Additionally, studies have explored how self-identifying with an underrepresented or minoritized group or a minority group can also impact that feeling, and there are a lot of factors then that contribute to keeping it perpetuated. Trying my luck to see if this other video is going to work. This is another example of very powerful video of women who are coming from different backgrounds who are talking about how growing up they were told, oh, you are a black woman, so you cannot do X, Y, or Z, or that there's one of them who talks about doing their undergrad or just general education in a very diverse environment in college, and they moved on to, yeah, it struck a chord with me, I'm from Rhode Island, so she's like, I moved to Rhode Island, and then I saw this place where there was a university which had, at that point in time, not as much diversity, and it was very shocking for them, but to adjust to that environment took a lot of work. So again, a very impressive video of personal stories of feeling like an imposter. So at this point in time, now that we know what it's about, I'd like to take a show of hands, how many of you in the audience here have experienced this phenomenon at some point? Thank you. So that seems like most people have experienced it at some point in time. How many of you, if you haven't experienced it, know or can think of someone else who felt like an imposter, you're like, yeah, I think that's what's going on here. So that's, again, a lot of people, so that pretty much makes it for the entire room, so I think I'm in very good company today. So what is the impact? I mean, like, what's the harm if you felt that way at any point in time? This picture says that it is correlated with higher rates of anxiety, depression, emotional exhaustion, burnout, and lower job satisfaction. Everything that's going to make you want to continue in a job, doing the work that you do, love your life, or not. Physicians tend to measure their self-worth through clinical, academic, or professional achievements, and I think all of us are familiar with the idea of perfectionism, being a workaholic as they call it, or being like, you know, you want that last full stop and that dot right in your medical record, you're correcting all the answers or the record keeping that you're doing. Expectations of self and perceived eligibility for success and recognition. There's always pressure, responsibility, and desire to manage work and life, including family. I think as physicians, what is usually not given as much preference is that we have families too. We would like to spend time with our children or with our parents, or if you don't have children, spend time doing things that you love. It could be traveling, it could be meeting friends, but then when we get in this track record of either academics or doing the professional work you do, usually personal life and that, you know, inner satisfaction takes a back seat. So these are the internal vulnerabilities that keeps this phenomenon going, but they're also institutional structures and barriers that can cause a lot of people, including women in minority groups, to question their place, talents, and accomplishments. And I think for the institutional structures and barriers, Dr. Wills is going to go into that in a little more detail. The contributing factors for this phenomenon. In physicians, it could be an unconscious bias. Nobody consciously wants to feel like an imposter, but it could be like a deep, secret, hidden feeling that comes up only when the right tone is struck. Low self-esteem, it's a possibility. Gender, I am not totally in agreement, but I do see that there are structures in place which make women feel that way, and it brings out things that also might be there already. Perfectionism, hierarchy in medical education and the culture of medicine. We've always done things this way. This is how it's done. That kind of hierarchy or that kind of approach can also create this feeling of imposter for people who haven't quite made it yet, or realized, well, I didn't want to all this time, but now I want to be a part of the people who are doing everything, but how do I get in? So the outsider feels like an imposter. This particular review I mentioned by Arthur because I found it very interesting, where they say comprehensive changes in medical education that consider the relationship between culture, identity formation, imposter phenomenon, and perfectionism are needed. And every word for me struck a chord as a doctor, as a physician saying, yeah, I think all of this need a little deeper dive to see how we can change the systems we work in. Protective factors, social support, validation of success, positive affirmations, institutional support, they all sound like key and buzzwords, but each of them have a lot of weight behind them. Social support, many people might not have. So if you're working in a remote area, or your practice is led only by you, or your family lives really far away, your children have grown up, or you're taking care of aging parents, your social support systems are very different. Or if you don't have as much external validation of success, and that is required from time to time if you're in a different kind of professional trajectory, and positive affirmations with institutional support. If you have a system which is always, which is facilitating an environment that lends to questioning of your abilities, it can be harder and more difficult to feel comfortable in your own competence and skills. Personal shared reflections of common experiences. I think having a friend circle, a group of people who know you and can relate to your abilities, your skills, and your struggles is always a protective factor in living through and processing through that shared experience. Individual changes keeping a record of success. Even as in attending now, it's been a learning curve. Now that I'm saving pictures that children draw for me when they've had like a good day, or they're like, thank you, Dr. Gandhi, and my name is spelled in all kinds of different fashions, I've learned to save them. Because I realize on those days when the world is, when it feels like the world is really hard to live in, and your day is really rough, and your patients are not doing as well as you'd like them to do, those little joys and those little successes make your day better and say, you know what? I think I can do it for another day. Tomorrow it's going to be a better day. And saving letters from your patients, stories of success, things that people have told you, cards that medical students write to you thanking you for your teaching, those can actually go a long way. And I know attendings who actually have a box saved with all these positive affirmations and reflections to collect and keep, and they're like, we're going to look at it when we retire. I think it's a brilliant idea. But yeah, I think the ones, you know, with your name spelled wrong, and then with hearts and bubbles around it, they have a particular special place in your heart. So in addition to that, positive feedback, celebrating accomplishments, seeking mentors and sponsors, this is definitely a protective factor. And we were talking about this at another presentation yesterday where, you know, a particular group can feel out of place or not belong, even if they've made it, if they don't have the supports to help them continue to succeed. Mentorship is required at every stage of a career to go into the next stage and be successful. And success is defined by your internal need for accomplishment and where you want to be. It's not the external level of success where you have to be the president of an association or the CMO of your hospital. For you, the success could be, or for a person, it could be running an excellent practice where I work 9 to 5 and then I go surfing in the evening. That's a measure of success. It's very personal. But to achieve that and to achieve that kind of work balance and also work within the institution and the challenges with institutional structures, mentorship and sponsorship goes a long way. And mentors can be different at every stage of career. So student mentors for medical students are very different from mentors for senior attendings. At my stage of career, I still do have a mentor and the mentors are different for different things that I do because each one has their own expertise. And I can't say enough about how I've been so passionate and driven by passion for certain things that I wanted to do. But my mentor has said by experience, I think this one, you've got to let it go. Let's come back to it another time. And they've been right. Institutional changes, increasing understanding about this phenomenon, not identifying it as a syndrome or as a problem or as something that's a flaw within a person, not saying that this is because you are such and such person or you have low self-esteem, but increasing understanding, developing support programs and a culture that does not punish mistakes. I think in the medical profession, we are self-critical enough that if a system is also telling you how to be and there are punishments, quote unquote punishments, in place for mistakes, it can feel very personal and lends to that feeling of being an imposter, lends to being more perfect and getting more workaholic. I'm being reminded because we have a special activity saying this is the right time. So we're going to hand out cards to each one of you. Do not look at it. Do not tell your partner or the person next to you what you have. But hold on to it for now because I have a few more slides and then we'll get to our activity. So in literature, there are also skills to measure the phenomenon. That is why I say there is no gold standard. But there are ways to think about it and there are people who are looking into it. Listed on this slide are some skills that, you know, you can go look into if this is an area of interest. But the limiting factors with measuring the phenomenon by a scale is that the definition itself is variable. This variable understanding about the dimensionality of the phenomenon, how it is applied, and how these skills can be used reliably, can measure what you really need them to, and then reproduce it. The one thing that I haven't spoken about is, you know, we are in times where people have multiple identities and there's an intersection of those identities. You could have an identity based on age, based on gender, based on sex, based on what you think about life, religion, and also your life experiences. And they combine in different ways and each one of them, in addition to your life experience, could contribute to this phenomenon in a variable manner. So personally, I feel measuring by a scale really does not give us reproducible results that you can use and say, this is how we're going to address it. How are we doing in medicine? As I was saying earlier, I started off with doing this presentation with the imposter phenomenon in women, and in 2019, more than one third of the active physician workforce in the United States was female. But when you think about the number of people or the number of women in academic medicine, this slide gives you a very good example of how the numbers are very different. And then when you think about leadership positions, how many women actually make it to top leadership positions? We are doing okay in the APA, and that's why I have this slide, because I think we've got a lot of work to do, but I'm glad to say we are doing the work as well with our first women president in the 1980s, from 1985 to 1986, to our current president, and we are welcoming a new incoming president now, but the last woman president was Dr. Brendel. So I think we're doing okay, but do we do have a long way to go? How do we manage it? I talked about some of the individual factors, and that is recognizing that it's a phenomenon, creating a safe space for discussion, and about this feeling, reflecting on what it makes one feel vulnerable, challenging, affirming statements to help people feel comfortable, reflecting on what you need to seek support, mentorship, coaching, self-reflection and reframing. These are important ways to overcome this feeling, and reframing losses is lessons. Reframing on what can be learned from a perceived negative experience, identifying what could have been done differently to change an outcome. This can also help on the path towards being more constructive, rather than critical and negative in thinking, and always knowing that you're not alone, because the way this works is when you feel like an imposter, you don't tell anyone, right? If it's like, oh my God, do I belong? But probably there are a lot of other people who are feeling the same way, and I think for me, I've grown comfortable with this experience by talking about it, and realized that I've had perceptions about people being successful, but they're probably feeling the same way in a room full of people, feeling like, oh, do I belong over here? Suggested strategies for addressing it individually. I think a lot of it we've already talked about, so I'm going to move on. The only other thing it mentions here is considering individual or group psychotherapy. Again, I want to be clear that it's not because we think it's an illness or a syndrome, but sometimes, if it is lending into feelings that are derived from personal experiences that could be traumatic or difficult, or you don't know what to do with it, it can be a good experience to explore them and unpack what's going on. Positive affirmations. These are some examples of positive affirmations. And this is a slide which talks about the institutional and organization level changes that could address the phenomenon. This we will go into detail with Dr. Wills' presentation, which is coming up next. And then societal and systemic changes, which help people feel a little more comfortable in their own space. Going back to the video that I couldn't play from Michelle Obama, she says, my advice to young women, and I would say this applies to everyone, is that you have to start by getting those demons out of your head. The ones that say, or the question I ask myself, am I good enough? That haunts us because the messages that are sent from time to time is we are little. Maybe you're not. Don't reach too high. Maybe you are not. Don't reach too high. Don't talk too loud. And the things that I was talking about earlier, saying the way we are raised sometimes lends into that feeling as well. And challenging that perception can help you think about yourself in a different way. With this, I think we're moving on to our activity with Dr. Wills. And while she's making it to the stage, on a personal note, I am a doctor who was trained in India for medical school. And I've been here for a long time, did my residency, fellowship training in the U.S. But there have been experiences along the way that I've questioned my place in just the profession, in academic medicine. I did residency in Philadelphia, and I was like, oh, boy, you know, for, again, self-perception for a brown Indian woman in America, I think I need to work twice as hard to make it, or I'm always going to be invisible in a room, not identified for my skills, but for a lot of other reasons that I do not want to be identified by. And that's exactly the reason I moved to this country, because this is my version of the American dream, right? You want to be recognized for who you are and be able to do what you want to do. So I was like, I need to get in the top fellowships. I did make it to a forensic fellowship at Yale and then to the child fellowship, and it was the best part of my training to actually see all these wonderful academics do what they do on a daily basis. And then I moved on to practicing as a child psychiatrist at Bradley Hospital, and I'm a faculty at Brown now. The reason I bring that up, it really doesn't change how you feel like an imposter at times, because when the specific situation arises, and you have actually external factors that play into your internal experience, it's the perfect storm and combination that brings up this feeling of imposterism every now and then. Did it make me feel better that I made it based on accomplishments? It did, but I think it still remains a work in progress on a daily basis to feel like you belong and to feel like you could be a voice for other women and other trainees and other faculty who probably feel the same way in many spaces that we are together. So with that, we move on to our activity. Good morning, I'm Cheryl Wills from Cleveland, Ohio, and I am Vice Chair for Equity, Diversity, Inclusion, and Chief of Child Psychiatry at Metro Health Systems, which is a public health hospital. We are pleased that we have increased our beds from 20 inpatient psych beds to 120, I mean, 112 in the last year. We have a lot to offer in terms of community by treatment and meeting the needs, but we also have a lot to contribute nationally. I often talk to residents about imposter phenomenon, which is basically a barrier to internalizing success. And today we're going to do an exercise because, as Dr. Tanuja Gandhi said, there are individual factors, there are interpersonal factors, and there are structural factors. And this exercise is designed to look at the latter two, the interpersonal and structural factors. So I've asked you not to look at the playing cards you were given for a reason. Because we're going to start to look at how this can play out. Most of us are familiar with playing cards starting with the ace, either at the high or lower, and I've excluded those intentionally, from the cards up to the king. So up ten, jack, queen, king. Based on that card level, you know that card has a certain amount of value. And the reason I've asked you not to look at that card is because I want you to show your peers the card and walk around the room and you're going to talk to each other based on the type of comments that you think that that person should get based on, receive based on that rank in the card. I'll give you an example. At one point, we did this exercise, and the kings and queens, people were going like this. Or it's, I just want to be in your presence. And then when someone had a four, someone said, I love that dress, that is fantastic, but it's more dessert, it will look ten times better on me. So based on that crank of card, I want you to talk with each other. So and then at the end of that, I want you to think about what your level is, okay? Okay. So. Okay, go for it. Just get up, walk around, look at, you know, show your card. Don't look at it, and people will respond to you or react to you or comment on you based on that level of the card. Instructions? What? Oh, basically, okay, again, talk to people based on the level of the card. I'm hoping that the recording is catching all these laughs. This exercise is really fun when you start to get into it, but we need to settle down. Please be seated. Okay, so as you can see, that was an interesting exercise, and I'd like a couple of volunteers to stand up and tell us what, show the audience your card and tell us what you thought your rank was based on how people reacted to you. You comment first, then look. Yes. Could you go to the microphone? And tell us who you are. Okay. So, my name's Araz Tawfiq, and maybe I felt like I shouldn't go straight to college. I should go to community college first and work really hard, and yeah, that's where—so, the number. I thought I had maybe a seven. Okay, and what do you have? It's too big. Okay, but you're right. You were not at the top of the heap. Okay, someone else, please. Go to the microphone. And a couple of you can line up so we can see a few of you so we can keep moving this ahead. Please step up to the mics. Tell us who you are and what your experience was, what you thought your card was. My name is Monica Taylor-Desire from Mayo Clinic, Rochester, Minnesota, and most people were speechless when they saw this card. They did not know how to describe it. I don't think—I had one person say Yowza, and that is quite a number. So, I think I have the lowest one. Okay, and what do you actually have? Take a look at it. I have five. That's not awful. Someone else, please. She's a queen in real life. Good morning, everyone. I'm Dominic Fernandez, Navy Psychiatry based in Japan. Yeah, like the previous doc, I had got a lot of pauses and hesitancy and, you know, a lot of political correctness. So, I think I have the lowest one. Okay, and what do you actually have? Take a look at it. I have five. That's not awful. Someone else, please. She's a queen in real life. Good morning, everyone. I'm Dominic Fernandez, Navy Psychiatry based in Japan. Yeah, like the previous doc, I had got a lot of pauses and hesitancy and, you know, a lot of political correctness. So, I think I have the lowest one. Okay. And what are you? You'll see. I'm a five. Someone else. Oh, Lee, this is tall up there. Hi, everyone. Come on now. So, I have five. That's not awful. Good morning, everyone. I'm Dominic Fernandez, Navy Psychiatry based in Japan. Yeah, like the previous doc, I had got a lot of pauses and hesitancy and, you know, a lot of political correctness. So, I think I have the lowest one. Okay, and what do you actually have? Take a look at it. I have five. That's not awful. Someone else, please. She's a queen in real life. Good morning, everyone. Oh, Lee, this is tall up there. Hi, everyone. Come on now. Jack Bruno from Boston. I only got like one usable piece of information and that was that there was someone like distinctly beneath me who like should do like a job that I shouldn't do for someone in the royal family, which I like kind of like was like, oh, no, no, please, like allow me to do that, please. Oh, no. Okay, so where do you think you, that number would be? So, I'm thinking of like, not yet. Okay, and what number do you have, or which card do you have? Okay, all right. So, let's see. But, this is not my card, so. Okay. more people. Good morning everyone, my name is Amalia, I'm an incoming first year medical student from New York. Welcome. So I feel like I got some like mixed responses with this one. I had a couple people look and kind of be like oh oh wow you must be having an especially good day, which made me think kind of higher up, but then there were a couple people that kind of just gave me the blank stares, which made me think lower. So I'm gonna guess right around the same, I'm gonna go like nine. Okay and what do you have? Ten. Beautiful. Okay good guess. Two more. Peter Kelly's my name. By the deference and respect shown to me, I was fairly sure I was a member of the royalty. Somebody commented that I'd done well to transition at my age. I think that they mean that it's a queen. Okay say who you are and give us some feedback. Just quickly, I'm Scott Guthrie, I'm a child psychiatrist in the Air Force, and I was, the very helpful thing was I was told I could be a lovely partner for a king that I ran into, and so I would also say I would be a queen. And? Okay well great. So how many people thought that was helpful to see how people can judge you based on external characteristics that you may not even be aware of? Okay. Was there anybody who was way off base when they thought and they look at their card to see where they are versus how people treated them? Nobody. Okay so one of the things we know about bias is that, or the imposter phenomena, is that it's individual how you're perceived, and that was your experience, the experience people described at the microphone, but also the interpersonal factors, how people viewed you based on a variety of factors including your card rank. So that can have some, bias can have something to do with that. There's implicit bias and explicit bias. Explicit bias is for example, I never buy red cards because I know I'm going to get ticketed. So you know what you're not going to do and you're aware of it. Implicit bias is although Sally says that she's fair, whenever she's collecting tickets, people with the blue shirts always end up at the end of the line. So not visually intentional in the eye of the person engaging in the behavior. And we see that a lot. And there was an interesting study in 2019 by Dearby, Heron, and West on which looked at medical residents in second and third year, white medical residents. And they did two things. They did the Maslow burnout inventory and then they did I believe it was self-esteem study. And what they found was, oh no a bias study. And what they found was in second year where there's a lot of inpatient demands and a lot of stress, the white residents who were more burned out were more likely to engage in implicit and explicit. So unintentional and bias that they weren't aware of towards black patients. In other words, they gave black patients a worse experience. And you can see how that can affect one's health seeking behaviors not only in mental health, because as we know there is no health without mental health, but in all other aspects of their health care. And while the physician patient interaction is accountable for 20% or in that range of health care outcomes, when that person takes that outside and externalizes them based on how the doctor treated them, it affects how they interact with their environment, compliance, et cetera. Now by third year, when the outpatient demands were less stringent, I mean the clinical demands were less stringent, more outpatient, you have more of a leadership role, and a little bit less gut, relative of course, then they found that the explicit, the intentional bias against black patients diminished. But the implicit bias, that indirect bias that is not intentional per se, stayed the same. So that tells us something about how we react to people based on our stress level and their perceived rank. And that contributes to imposter phenomena. And that happens in a variety of different settings, but the fact that it's happening in medicine is extremely concerning because that has long-term potentially life-affecting outcomes, as well as impacting transgenerational trauma, so families across generations. So let's move on to a couple of other definitions and such. Prejudice is a belief that's often rooted in unfair assumptions. And those cards gave some unfounded assumptions or unfair assumptions, just because this is how society views the card, or this is how we've been conditioned, doesn't mean it's really so. Discrimination is an action motivated by prejudice, deliberate or otherwise. So when we made our comments to people based on our assumptions of where that card rank was, we were being discriminatory in one way or another. Microaggressions is a term that was coined by Chester Pierce, who was an APA member, a Harvard psychiatrist, and actually headed the APN at one point. In the late 1960s, he came up with this term to describe the passive indirect slights that whites gave to blacks, particularly southern whites, to blacks after discrimination in housing, et cetera, voting rights, et cetera, were outlawed. Over time, people like Darrell Wing Sue studied this and reviewed it, and it's not limited to blacks, et cetera. It can happen in all types of situations, but it's usually directed towards the non-dominant group. And this became so big that we started looking at it in terms of depression, anxiety, drinking in college students, retention in college, and other environments. And also, we found that it is indirectly related to suicide spectrum behavior, but it's mediated through depression. So this is a very serious concern, and it's become so commonplace that in 2017, the Merriam-Webster Dictionary entered it into the lexicon. So that tells you something about how important this is. Let's look at a couple of other terms in terms of interpersonal bias, and that can contribute to imposter phenomenon. Othering, the assumption that a person is not a member of the dominant group. That's also marginalization, and it is not limited to race or gender. It could be height. It could be academic rank. It could be you don't qualify for this fraternity or this sorority, or you don't belong to the flower club in your community. There are so many ways. Nobody is immune. It can occur within faith. It can occur within social groups. If you're not part of that in crowd, and I remember when I was chairing the APA Presidential Task Force on Structural Racism, before the committee, we had our first meeting, I had a talk with an African American person who was not happy with the choice that I was selected to chair the task force. And what they said was, you're not authentically black. You don't know the true black experience. You don't walk in black spaces, et cetera. And my reaction was, this person knows nothing about me. Now, I could have responded to that in feeling inferior or left out or just marginalized in that way, but I just took it in a different way, reframing that this person is apprehensive, uncomfortable, not comfortable with asking me the questions that they really want to know. But that could have taken another toll on me, and I could have led to the things that Dr. Gandhi talked about, the anxiety, the depression, the not functioning, I could self-sabotage, et cetera. So again, this can happen to anyone. Intersectionality is the combination of all these things, a complex, cumulative way in which the effects of multiple forms of discrimination, such as racism, sexism, ableism, classism, height, suit size, other things, but we usually use that into more dominant or more physiological and intellectual capacities, but it's more than that. And how those things combine, overlap, or intersect, especially in the experience of marginalized individuals or groups. So while we look at these groups as a predominant group, all of us can think of other ways when we may be the other or we may be marginalized. So this has a number of components, although it's predominantly used to describe marginalized groups. Micro-inequity is something we don't often talk about, but we see it every day in our practices, in our families, in our friends, and in ourselves. And that is the experience of being undervalued, marginalized, overlooked, and devalued because of one's status as a minority. And again, that is situationally specific and it affects all of us in different ways. And then there's privilege and entitlement. And this one I love to talk about because people think of privilege based on a stereotype or we're a woke society or not a woke society, but I think that Peggy McIntosh best described it in a way that we can understand this. In 1968 or 9, she wrote a seminal article about white male privilege. And then over time, she realized that that metaphor, the metaphor of the invisible knapsack could be used when discussing white privilege because she realized how she was a professor of women's studies at Wellesley and she realized that relative to her black and other colleagues, she had advantages that they did not. And she wasn't aware of it until she stepped back and said, wait a minute, this is the same thing as male privilege. And what she said was that white privilege is like an invisible, weightless knapsack of special provisions, maps, passports, code books, visas, clothes, tools, and blank checks. And a key of this is it's given to you at birth. It's a backpack or a knapsack of unearned assets. And the individual is oblivious to its existence but counts on cashing in every day. So all of us have a knapsack of some type. Some may be burlap, some may be Kevlar, some may be a paper bag, some may be a Ziploc. But we each have them and the tools in them we count on using every day. Now some of us are more aware of those tools than others, but it's also situationally specific. For example, if you are Jewish and you live in the mail and living in New York City or say California, you may have a lot more resources and that backpack may be Kevlar because of that environment. But if you move to South Dakota, that may change. So it's situationally specific. Just because I'm African American doesn't mean I have privilege or a stronger backpack in different settings because in some settings I have a stronger backpack than you. You know, when we went to the opening ceremony, I'm a trustee. I was on that stage. My knapsack was different than your knapsack. So it varies and we need to be cognizant of this because it varies based on the circumstances. But when I was with friends and I went to pick up some artwork on a weekend, I had purchased it during an art show. They asked me why I was dressed up. I said for work because they were in jeans and ski jackets. I said I'm going to pick up my artwork. They said, but it's a weekend. We're just going to hang out. I said I'm going to pick up my artwork. We all walked in. They're both older white women. We all walked in. I got stopped. May I help you? I'm here to pick up my artwork. For which artist? My artwork. I purchased my artwork. You purchased your artwork? Whose artwork did you purchase? So at that point I pulled out all my papers. I pulled out my driver's license and I just said, if you'd like my medical license and my passport, I have those too. At which point I received an apology. Meanwhile, my friends had gone through all the artwork and looked at it and when we got out in the parking lot, they were disgusted. They said, wait a minute, we didn't purchase anything. How did we get through and you didn't? I said, because you guys went in and I didn't, but I was there to get my artwork. They said, but why is that? I said, well, why do you think I dressed up for work? Well, and they were miserable all day. How can you be upset? And I said, if I allow myself to be so worked up from that, there's so many things I will not accomplish in life. I will not have joy. I will not be able to enjoy myself. So this is just something a part of who I am and what I need to do so that I can move through life with a level of comfort. I was prepared. And they were miserable for the rest of the day. It's like, you're killing the joy. I got my artwork. I'm happy. We're not. So that just gives you an idea what privilege can be like and we all have it in different circumstances. Okay. And then there's a component of interpersonal hostility. This one says, one sheep says to the other, uh, you're the fastest among us, the strongest, and you're really good at singing to the moon. For some reason, you should be proud. I'll be honest though. There's something about you that just screams false. That would be something that can trigger the imposter phenomenon after all you've accomplished and you've measured up or you may even exceed those expectations in your department. You may publish more books than people. You may have 150 articles and somebody who has three can say this to you because of how they view things. And if you internalize that, that can create problems for you because they're going to keep going on doing what they're doing. So you have to engage in self-protective mechanism to encourage and support yourself. Many of which Dr. Gandhi mentioned. Okay. Let's talk about some structural biases. Okay. Now, structural considerations include systems such as the hierarchy on the cards that perpetuate inequality and bias. Those systems are responsible to evolutionary changes in society such as racism. For example, we had slavery in this country and then once slavery stopped, we had the adrenaline pro laws and then we, um, the civil rights act of 1964, which was the first time in history that blacks were not legally, it was illegal to discriminate against blacks, but you realize that that means that 85, as of today, 85% of the time that blacks have been in this country since 1619, it's been under legalized discrimination. So that puts a different spin on where blacks are in society today, but you can also look at what happened in Hollywood, and McCarthyism, and all of the blacklisting, et cetera, and how that impacts people's function, their perceptions of where they stand in society, and other people's biases. Because people don't think the way you or I think, and we don't think the same. So each person comes in with their baggage, their perceptions, and what they need to perceive that they're engaging in self-protective behavior. So it may not be that we are that, but it's being projected onto us. Okay, so an example of direct bias or would be Hurricane Katrina. For example, in Hurricane Katrina, there were two experiences. One was in, I'm a Hurricane Katrina survivor, by the way. In Metairie, Louisiana, they set up, the city council set up a rule that no street businesses or street vendors could be on the streets that were not established before Hurricane Katrina. So this excluded a lot of Mexican and other vendors. So there was a Mexican physician who went to city council, he was actually a member, and said, what is this, you're discriminating against Mexicans, why can't they earn a living? They're helping us rebuild the city. I'm Mexican. And they said, no, you're not Mexican, you're one of us. And don't forget that. But also in Chalmette, Louisiana, where I used to work was predominantly white, that is east of the Ninth Ward, that was a predominantly white community. And they actually enacted a statute that said you could only sell property, your property, after Hurricane Katrina to a blood relative. So these biases do occur. And if you happen to get property in that area, and everybody's feeling that, that will impact how they perceive the cards you're holding. And their reactions to you can affect how you perceive yourself as an imposter or as less than. Okay, so some systemic factors are very concerning. Because when we look at women imposter phenomena and minorities imposter phenomena, some studies show there's no difference. The difference though, one of the big differences is the structural bias. And we don't look at that. We look at imposter phenomena in terms of researching the individual, rather than the systems that perpetuate that. So if you're in a system that's accommodating support, say you're a woman and you go to a women's college, you will experience some types of bias there. But the bias won't be male versus female. So, but if you go to a CODA education environment, that bias will be competing against gender issues also, and gender biases also. And that was one of the reasons that women's colleges evolved in this country, and on women's colleges there's those stats of higher percentages of women going into science, technology, engineering, and math. So with Finestra, Begheni, Stoker, and George, and I apologize if I mispronounce the names, in 2020 they published an article that said, research overlooks how the social context, that is systemic structures, may inform a person's tendency to feel like an imposter. So what they're proposing is that we shift some of that research from individual analysis, looking at that person, to the systems that perpetuate this. So looking at the systems and how they function and how they contribute to imposter phenomenon. How these systems and structures are barriers to people feeling successful and if they're belonging. Now, sometimes it's not intentional. We can look at how implicit bias can undermine advocacy. And this is Rachel Juntel, and she was 18 years and about three weeks old at the time that she was on the phone with Trayvon Martin the night that he was killed in Florida by George Zimmerman. And Jelani Cobb, who is the Dean of Columbia Journalism School and is also a New Yorker staff writer, said, and I quote, social media commentary on Juntel began nearly as soon as she began to testify. Crass assessments of her weight, looks, intelligence, and intelligence from some white observers competed with a cocktail of various vicarious shame, embarrassment, and disdain from some black ones. So, basically, a lot of people from all sorts of walks of world, cultures, et cetera, were biasing her. But, you know that the prosecutors in that case wanted a conviction. But they forgot about some things. First of all, Juntel spoke, did not speak English at home. She spoke a dialect of black English in the community. She spoke Creole French, and she spoke some Spanish. She also had a learning disability and a fourth grade education. And she never learned to read cursive. So you put all of that in one package with a heavyset black teenager who's been severely traumatized, and you put her on the witness stand without adequate prep, not thinking about how bias and imposter phenomenon and an all-white jury would respond to this. It wasn't intentional because they wanted to win this case. But that creates problems. The other thing is that she had told people, her friends, that she had to go, I think, to the doctor on the day of Trey John's funeral. And she has to talk about to the jury why she lied about that. It's making her look deceptive. But remember, this is an 18-year-old who had the most horrible thing happen on the phone, and she was helpless to deal with this. She had not processed this trauma, she had not been in therapy, and when she's on the witness stand, she's 19. So let's take a look at that, and hopefully this works. It worked earlier. Okay, so basically what she's talking about is she's traumatized and she's explaining why she lied. And the reason that she lied was because she was too traumatized. She just couldn't see that body again. And this comes across on the witness stand, and that increases her credibility a little bit. But think about that. No prep for trauma, not to mention her other cultural experiences, et cetera. And at one point, the defense attorney gives her a copy of her trial transcript in cursive. She can't read it, fourth grade reading level. None of this was brought out to prepare the audience, or the jury, or the public for this. So they judged her based on it. That was not her fault. And that may have contributed to the outcome in the trial. Let's see if this one works. I don't know how you got these to work earlier, Dr. Gandhi, but okay. Let's come back to them in the end. Okay, so basically what they talk about, there's a trial consultant talking about how she functions. She rolls her head, she's arguing back and putting the defense attorney on trial, et cetera, because nobody coached her on how to conduct herself in this situation. They just let her be her true self, which wasn't fair to her. It wasn't fair to the Martin family who lost their son. It wasn't fair to society, but it wasn't intentional. And that's why we need to be cognizant of our biases. And one of the things, there's an article that was written about this, and one of the things that the authors suggested was that in a future, you use interpreters. You give the jury the trial transcript so they can understand what's going on. And you make the audience and the jury aware of those biases. And I was talking about this to a group of lawyers. And afterwards, one lawyer said, I had that exact thing happen. And they basically gave the transcript to my client who was illiterate. Only that client was a little bit different in his approach, and he said, Wilder, if you're giving this to me, you know I can't read or write. That's not fair. And because he advocated for himself, that worked in his favor. But the attorneys told me, that taught me exactly what you're showing. We have to be aware of that. We have to find common ground. And one of the things I was talking about with the attorneys is helping the jury and the audience, the public, especially if these things are going on trial in public opinion too, to see their clients as humans. Not as defects, not as bullies, et cetera. It's important to know that. If you knew that English was not her first language, that helps you understand. If there are cultural differences between the jury and the audience, that helps you understand. Okay, so let's move on. In terms of individual solutions, we went, Dr. Gandhi went through that. So let's look at the rest of the solutions we can do. Okay, there's some more individual solutions. Healthy lifestyle, being selective. And this one, I don't think she went through as much, but this is something that is very important. You need to surround yourself with a team of advisors. Each person has a different strength, weakness, and the role, as she said, may shift from time to time. You know, I work with people who know me personally, I know people who know me since I was a resident, people who are new to me based on where I am in life right now and professionally, people who have achieved or have a different spin on what I might like to achieve or can open my eyes to other possibilities. And I know I can call on them when I have concerns, et cetera, to help me grow so that I don't get caught up in the minutiae of this imposter phenomenon. And it works wonders. You know, it makes me aware, or they'll call me on this. They'll say, well, I said, well, is that what I'm going for? No, I didn't view it that way, Cheryl. This is how I viewed it. And then I can take all of that in and then move myself to the next level. But it's helpful to have those kinds of advisors. In terms of self-care, again, exercising, mental health self-care, and other interactions, et cetera. Also, goodness of fit. I'll go back to that slide quickly so I wanna give you an example. In terms of goodness of fit, I remember one time when I was going through some of this imposter phenomenon such, why am I not advancing, et cetera, and I just kept beating my head against the wall, so to speak, and then it came out. The person said, I'm jealous of your success. And I was like, wait a minute, you're my supervisor. It makes you look good, too. Why are you competing? I should be where you are. Huh? So I was internalizing this, and it wasn't my issue at all, but I was being made to feel as if it's my issue. And that's where the advisors come in, because they can help you reframe, contextualize this, and also focusing on self-care is key. Okay, but that goes the other way. If you're the person looking at the card and deciding how to respond to these things, if you're looking at your own issues, your own concerns, your own differences, and your own stressors, that can inform how you are responding to things, how you manage stress, and how you interact with others, and that can go a long way to addressing the concern, too. So when you're looking at this from both sides, you have to question whether there's a goodness or fit in your job or other aspects of your personal or professional lives so that you can move ahead, reframe these things, and cherry-pick what's best for you, weighing the risks and benefits. Okay, the interpersonal barriers. Anti-bias education can be helpful, but the studies show that when you force it on people, you may not get as much benefit. So when the APA Board of Trustees went on underwent diversity training, some people said it wasn't enough. It was watered down. My perception was it was perfect. Why? Because out of that, we were, and the coaches, the program, it was a six-hour training. They acknowledged that we were all at different stages, but when we left that six-hour training, there was a common ground, and that helped us move into the future, and there was a noticeable change in dialogue. The goal wasn't to hammer it into people's heads, but to find a common ground on which we could predicate future discussions. Our cultural competency. There are problems with cultural competency. While it is great to understand other cultures, competency implies that it is a complete, a determinate process, rather than an indeterminate one. But, in other words, I'll give you an example. At one point, I wanted to learn more about indigenous populations and mental health, so I went to the Navajo Nation, and practiced for a while. I thought the opportunity was the opportunity of a lifetime, so I read a lot and found out what I could learn, and I felt that I had a certain level of proficiency with the basics, but I didn't go in saying, this is how you people function, the book says that, et cetera. I used that to inform questions that I posed. Well, I've heard about this, can you tell me more? And just opened a discussion because it opened to dialogue, and that's where cultural humility comes in. It involves critical self-reflection. How am I, where am I, what's going on with me, and how does that inform how I relate to others? Openness, being open to learning, and it may not be what we want to hear or what we expected, but being open to it. Being non-judgmental and being curious, and that has been shown to improve healthcare outcomes, and it also makes our jobs easier because if you're improving healthcare outcomes, you're like, hey, I'm not so bad, but it also reduces the potential for burnout because you're less stressed. But when you're using that to inform this, you continue to grow and open your mind, and that opens possibilities, and that may inform how you relate to your advisory team, too, or select people for your advisory team. And then codes of conduct, as we've seen since 2020 with the pandemic and civil unrest, more of those codes of conduct have changed, and earlier this week, I read in our anti-bias policy at our hospital, one thing, one of the definitions of bullying is intentionally or otherwise obstructing progress and task completion. So that is not what people generally think about bullying, but if you have a nurse who won't take off your orders or if you have someone who's not doing their part of job and undermining the process in our hospital, that is considered bullying. So that gives a whole different dynamic or spin on that dynamic in terms of how you relate. You also see more hospitals saying, if X, Y, and Z happens, we're not tolerating. This is the code of conduct. In one case, I talked to a resident who is African American and she was working in a residency, and the patient told her he didn't want any, in words, treating him. So she walked out, went to her supervisors, they told her to go back in there. He said, I told you, I don't want you in here, blah, blah, blah. She went back to her supervisors, they forced her back in the room, and then they heard this patient screaming and going bananas. And then they finally came in and worked with the patient. They failed that resident on failure to establish rapport. Now you take another hospital that is engaging in all these policies and empowering their staff and codes of conduct and reducing the contributions to bullying and imposter phenomenon, et cetera, and that same resident, in a similar situation, she has hijab, and she goes in and there's a nasty comment made, and the patient doesn't want her treated. So she goes back to her supervisors, and the supervisor, the emergency room director, and the resident come in, the room, we understand there's a concern. Well, she's a valued part of her team. We have utmost confidence in her skills and we have designated her because of our confidence in her. Skills to treat you. Now, if you choose not to be treated, you're free to go elsewhere. That is your choice. Of course, you're gonna make sure it's not part of delusional or PTSD trigger or something like that, because that would be a little different. But in general, if it's just the bias because of your belief about this person or this system, then they're standing by their residents and part of the team. Now, which resident would you want to be in that situation? Which one do you think had less emotional damage based on the experience and felt that they were able to affect change, they're a part of the team, they're not less than? Okay, so one of the things that, another thing that's coming up is email etiquette. We're being more particular about that. Also getting some, I've been talking with some members and they've telling me about, they have concerns about how their colleagues are posting things on social media. That can contribute to problems also. And people don't realize that patients read those things too. So you have to be cognizant of how you approach these matters. And sometimes it's not intentional, but once it's out there, it's out there. I'm being clear about prohibitive behavior and accountability. When you are accountable as your colleagues are and it's equitable, a lot of this stuff diminishes. So in terms of systemic change, we need safe spaces and basically, or I should say comfortable workspaces because if you label it, say, safe, do I know that it's safe? I don't know, I just know you labeled it safe. I can walk in there, maybe it's not safe. It might be safe for you, but not for me. So we have to be cognizant of that. Just labeling it is not sufficient. Inclusive workspaces, because that's where we exchange dialogue, we get to be comfortable, people we learn, et cetera. Having opportunities for people to exchange and experience things. For example, the APA, based on our consultants on anti-racism and inclusion, one of the things they do is they do cultural lunches, they go to events together, they learn about each other's cultures, et cetera, and it strengthens them because once you learn about other cultures and such, then that may help you with dealing with the next member who has concerns, et cetera, because you're a little bit more familiar. It improves your cultural competence a little bit, but you can use that while you're humbly approaching them to learn more and be more open-minded, which means you're engaging them more, you're making them feel valued, and you're growing. In terms of equitable opportunities for professional growth and leadership, that's a big one. Finding common goals, flexible work schedules and such, because especially in this day, we have that more than ever. Promoting wellness and creating opportunities for cultural exchange and engagement in the workplace and elsewhere, which is what I just gave an example of. Okay, we talked about mentoring and sponsorship and equitable corrective options. Now, in an ideal situation, we'd have something like this. I'm gonna tell you a little bit about this. In psychiatry, we prescribe a good amount of lithium. For generations, physicians have been taught that there's a difference between the level of glomerular filtration rate in blacks and whites, and that's based on the estimated glomerular filtration rate. Excuse me. Now, Dorothy Roberts, who is a law professor at the University of Pennsylvania, was a Robert Woods Johnson Fellow, and she went back as part of her project there to see why the glomerular filtration rates were different in blacks and whites, and she traced it back to the 1920s or 30s or so, and it was a case of Ipsy-Dixit. Some professors said there's a difference in tolerance for whites and blacks in renal function, and it stuck. For generations, we used this estimated glomerular filtration rate, and for generations, the number of black patients who had renal failure was not recognized until a later state of disease. So if you had a score X, basically, and you were white, you were diagnosed with renal failure and you went to treatment. With blacks, it waited until there was even less renal function because it was thought they could tolerate more, and so they were being referred at a more severe state of disease, which means the prognosis was worse, the risk for multi-system organ failure was worse, and the likelihood of you being eligible for transplantation was worse because you were closer to end-stage renal disease with multi-system organ failure. Now in the recent years, there was a movement to change that, and the research and data started coming back. So even though blacks had a two to four times higher incident of kidney failure, they discovered that the estimated glomerular filtration rate increased the rate differential by as much as 21%, and again, I said, it made it harder for blacks to be eligible for transplant. So what's happened with that, in January 2023, February, a decision was made by the U.S. Organ Procurement and Transplantation Network that all U.S. transplant centers must identify and subsequently back-date wait-listing times for black transplant candidates with quote-unquote demonstrated disadvantage due to prior race-based equations. In other words, if you're on the transplant list, they look back to see how long you were given the wrong diagnosis or you were under-diagnosed due to that bias, and that can lead to 17 to 19 months adjusted on your position on the transplant list. Now that's going to require a lot of work, but it definitely is equitable, and if we can start to move in that direction in terms of professionalism, et cetera, and this is showing it can be done, then we can move mountains. So with that said, I'd like to open this up for discussion, and Dr. Gandhi has some test cases. Thank you. Go ahead, please. For anyone who's leaving, if you have your card, just leave it on the chair, we'll collect it in the end. But I hope all of you stay for another 10 minutes so we can do some questions and discussion. Go ahead. Thank you. I really don't want to be making this question or statement, but to kind of walk the path that I want to be walking, I feel like I must. So I just kind of wanted to bring us back to the activity and kind of address something that came up during our debrief, in that the majority of this room laughed at a joke made about the idea of someone transitioning or receiving gender-affirming care in older age. And I just wanted to invite us to think about that for a moment. Again, I assume no ill intent. I assume no malice. We left that debrief and then talked about the slide, I think, next was on microaggressions, microinequities. And I found myself really activated as we moved into that next session. And couldn't help but think about the irony in that transition. And about how I hope myself to become a trans elder. And I love my trans elder so much. And that people transitioning at a later age face this intersecting pressure of ageism and transphobia. And as a burgeoning professional, burgeoning clinician, I really battle with being a trans person who is working predominantly with and for my community. And I hope my clients are people above the age of 25 someday. I hope to be seeing people in their 60s soon. And I just wanted to invite us to think about that a little bit more. Because I wanted to leave, I wanted to run after that conversation. Well, thank you for bringing that up. It didn't happen once. It happened more than once in this group. You're absolutely right. And there was the issue of age. And there was this issue of transgender and queen, which is a stereotype. Now, again, I assume in this environment, in this group, that it wasn't intentional. But you appropriately bring up the emotional damage and the otherism and the less than that can occur of that. And we just must be cognizant because none of us is immune. So I really applaud you for bringing that up. I really appreciate anyone who takes a moment to reflect on that. Again, not canceling or exiling or calling out, but rather just, I think this is a really rich opportunity to reflect or think, if we can't do it here, where can we? So thank you so much for leading the session and thank you all for your engagement and being here. And again, thank you. I have to say, it's commendable that you stayed because these activities are geared to bring out certain feelings. And we were discussing if we should even do the activity. The reason that we agreed, and for me, it was even talking about this activity brought up those perfect moments that elicit that feeling of being an other or an imposter in different ways. And we grappled with the situation a bit saying, when we do it, how are we gonna process what comes up with people after? And we were hoping it happens in the process of doing the discussion. But I wanna acknowledge that it brings up uncomfortable feelings. And so for anyone who's still having lingering uncomfortable feelings, you have our support, our gratitude, and an apology if it still lingers on. But I want us to take that and continue in personal and shared self-reflections, just like a wonderful colleague brought up now. And I forget your name, so I apologize. But this is exactly the activity and the intention. Because I think in our workspaces, we have students, we have other colleagues who are probably experiencing this and saying, well, it must just be me. Or, well, it's just a part of working in this profession or in this particular place. And sometimes I wonder, is it okay to just attribute it to well, it is and not address it and bring people in? There are different ways of thinking about it. But to me, it feels like that's an opportunity to address, to talk, and see if we can do it differently. Because that's how we are acknowledging there's this feeling of imposterism, and we're all contributing to it, consciously or unconsciously. So thank you for staying, and you've enriched our discussion by contributing your personal reflection. One other thing, we have the whole spectrum. But until you said you were trans, it didn't even occur to me. So we're all in different places with this. But again, thank you. Well, thank you very much for a very interesting session. Very thought-provoking. I'm Joran Bolin from Sweden, and I'm a psychiatrist, but I'm also a hospital, used to be a gynecologist and obstetrician. So, and I've been working for a few years. I'm an ex-exchange student, too, for Youth for Understanding, 53 years ago. So this was very interesting. My thought was that when you have this feeling of being an imposter, you're really set outside your zone of comfort. And that's a reaction to that situation that will happen more frequently when you're younger, and when you have people who are trying to shrink your comfort zone. And I think that's a way to mentalize it, to understand it, and it's something that's necessary when you're young, if you want to grow and expand your comfort zone. I also think it's important to find a way to, we're always criticized by, it happens all the time, and to find a way to put this into different groups. You have the constructive criticism, where somebody's trying to help you to get even better. You have the skeptical criticism, when people are raising questions that can be interesting to find an answer to, that can be useful. And you have the hostile criticism that should be ignored or fought back at. Yes, thank you. Thank you. A very interesting point of view. Would you identify yourself, please? My name is Valerie Poore, and I run an organization for borderline personality disorder. And I train families in how to deal with their borderline loved ones. And in borderline personality disorder, we talk about acting as if. In other words, people with BPD have many, many difficulties in interacting in the world, especially with strangers, and they will act as if they're okay. The prime example would be Princess Diana, who was diagnosed with borderline personality disorder, and yet you can see her looking like the most gracious, lovely, accomplished human being, and she also has all of this internal stuff. I also teach mentalization-based therapy, and we teach implicit and explicit feelings. And all I could think of while you were talking about this is that this imposter syndrome is describing how people with mental illness feel, and that they also have the difficulty of being super sensitive to other people. And when other people are treating them in a certain way, they pick up on it, and it then will trigger their reaction. So making parents aware of implicit and explicit bias coming out of them towards their children, towards their loved ones, is incredibly important, because this is all unconscious behavior that, go back to psychoanalysis and Freud, we have to remember that. This unconscious behavior is affecting our interactions all the time. And I'm glad you brought it up, but implicit and explicit bias is not just racial, it's expectations, it's relationships, it's everything. And I think we need to be more aware of that. So I thank you for bringing this to everyone's attention. Thank you. We appreciate your comments. Morning, my name is Omey Malutum, second year psych resident. Could you speak up, please? My name is Omey Malutum, second year psych resident. I have two questions. The first one is, is being conscious about our biases enough, or we have to take a step further? Second, the question is, if we have a patient who, I am a Muslim, I am an immigrant, and I practice in Ohio, I'm pretty sure if we go to specific areas of Ohio, many of the, maybe more than 50% of the patient, if they know that I am a Muslim, they don't want me. Could you speak up a little bit more? Yeah, if they know that I am a Muslim, they will not me as a provider. For me, I can understand where they come from. I know how the media is treating everyone. So I'm okay with having them as a patients. So do we ask this patient who says, I don't want this provider, and tell them this is the only option you have? Or we ask them to look for new providers? At the same thing, other question, what about emergency situations? Because myself, I saw many patients who, for example, did not want to see a white provider. Other patient did not want to see a Middle Eastern provider. And I felt that we did not give the full assistance for these patients because of this. And this patient was unfortunate because I was on day and the next person was on night, and both of us were from Middle East. So that person was unlucky. And I felt that we did not give that patient the full assessment they needed based on that. Still, we have to think about the media and how everyone is looking at Muslims and the whole thing about Islamophobia. Thank you. Thank you. You wanna tackle that or should I? Well, thank you for your comments. I think you're absolutely right. I don't think it can ever be enough, but it's a day-to-day process. I often am told that people want black provider. It was once I was even told, even though you're a geriatric psychiatrist, if you don't bring more black doctors to, even though you're a child psychiatrist, if you don't bring more black psychiatrists to this hospital, I will make you see the geriatric patients. And that was in writing. Not appropriate at all. Perhaps even illegal. The key is to help patients understand that what they're really seeking is a competent provider. Someone who's going to have that cultural humility. Someone who's going to consult and learn and try to understand where you are and what you're dealing with. You can have someone of the same race or faith or et cetera, but they may have biases within that faith, et cetera, that are not conducive to your emotional wellbeing. And I will refer to a competent provider. I say the highest honor I can give is I will refer you to somebody that I would refer a family member to. Because I believe that person, even if they may not have all the answers, they're humble enough and committed enough to try to learn more and to understand where you are. Also, the hardest person for me to treat is someone like me. Why? Because of the transference and the counter transfers. You know what I mean, doc? No, I don't. I want to understand your experience. You know what I mean. You're black. I'm black. Well, you know what? If you had an identical twin here, and I had an identical twin here, each of us would have a different perspective of this situation. What I'm trying to understand is your story and your experience and how it is unique to you. If I'm not doing that, then I'm not doing my job. You know, I think the other thing you bring up is that what you're experiencing is their perception if you're being Muslim. And it almost feels like you're expect, it generates a sense of apology, saying, oh my God, you don't want me to treat you? Did I do something wrong? And I've had people come up and say, it almost feels like I'm apologizing for my entire identified minority, saying, I am so sorry this happened to you if there's a negative experience. And I think in those moments, there is a lot of what's happening as an external vulnerability, and then there's some that's internal, and then some that just is, and you can't change the facts of the situation, and every time you get better at maneuvering it. I still struggle with the if I don't want to see you as a doctor, what do I do kind of situation, and I've gotten better at it. But in situations where it's possible with patients to bring it up back for discussion is a therapeutic moment. You obviously noticed my accent, and there's certain words which are very funny to my pediatric patients. So we've used that as a moment to laugh together, and say, what did you hear? And sometimes I've literally fallen off my seat because I thought that was ridiculous yet so funny, and I didn't think this is what they were hearing me say. But we've brought that back to say in family sessions when things have been misinterpreted or misheard, I'm sorry, it must be my funny accent. I don't think it's funny, but it just made the moment lighter and gave me an opportunity to lean in and explore what does this mean for our treatment process? But then again, going back to this feeling of an imposter, as one of our wonderful audience members said, it's constructive criticism. I take that as constructive feedback in appropriate situations for myself, and I think I've grown more comfortable doing so, and a lot of my words are not so funny anymore. Did that answer all your questions? Yes. When I chaired the Structural Racism Task Force, commissioned the Council on Children's Mental Health and Child and Adolescent, Council on Children and Adolescents and Their Families, excuse me, and they did produce a document, resource document, which is on the APA website, how to talk to children and their families about racism. And it contains some case examples that are very useful. I know the Geriatric Council's working on a different variation of that, so APA is trying to help with that. And then additionally, we have La Salud Mental, which has come out in the last year or so, where our Spanish-speaking members are translating documents and resources in Spanish. So it's a bilingual website that contains mental health resources that are growing. So APA is trying to be cognizant of this and giving us resources to deal with a variety of matters. But again, when you're having those types of feelings and stuff, somebody on your advisory committee who has experience who can get that, and it may not just be your faith, it may be of a different faith, but who has had similar perceptions, can offer you wisdom, guidance, and support. And you can, you know, you never know. I learn a lot of things from young people. I learn a lot of things, I'm showing my age now. I show, I learn a lot of things from residents, things that never occurred to me. So it's a bi-directional exchange, and it's very rich, and I look forward to it. I think the one thing I want to add is that by no means this diminishes the impact of the experience on the person who's treating patients who say, I don't want to see you because. So say, I don't want to see you because I don't like the religion you practice, or the way you look, or the color of your skin, or where you come from. Knowing that there are trainees in the room, and many of us are also teaching trainees and helping out colleagues, there are situations where it is important to get a feel for what the exact situation is like, the experience for both parties, and have a plan of action. There have been situations where our trainees have felt uncomfortable, and as a faculty, I think to myself, is that a situation I want to put myself in? No, then I wouldn't want my trainee to be in it either, and we think of a plan B, saying, can we swap this patient out? Can I take them out myself? Or I would volunteer to join family meetings, which are difficult, because it might be helpful to have an additional set of eyes and extra skills to smoothen out the process. Even at faculty level, we've exchanged cases because it is about the patient and the therapeutic process, and the more it gets into that transference, counter-transference personal space, are we taking away from treatment, or are we adding to treatment? And depending on the setting, say, you know, you mentioned emergency settings, you can't really do therapy and explore this further. Then you think about what is the best thing to do for the patient, and in certain unsafe situations, even for the doctor, so how do we make this better? And with that said, we thank you for your time. We're over time now. If you have additional questions, we'll stay here for a couple of minutes or comments, and we appreciate any feedback you can provide us to help us offer more to others. And again, thank you for being a wonderful audience. Thank you.

imposter syndrome

Dr. Tanuja Gandhi

Dr. Cheryl Wills

interactive session

self-doubt

medical field

biases

structural factors

burnout

mentorship

inclusivity

systemic influences

professional environments