riverside_copy_of podcast #1 wilderness medicine_adry's_studio 0:01

Hi, I am Dr. Adrian Silver, and I am Dr. Fri. From the ER to the great outdoors, from clinic, to the quiet corners of the mind, this is life and practice. Today we're gonna explore a topic that many educators are thinking more and more about in clinical training environments, and that's implicit bias, microaggressions, and how we support learners in clinical education. These issues can show up in subtle ways, in teaching, in evaluation, and in day-to-day interactions. And in the clinical setting, they can affect not only medical students and residents, but also faculty, staff, and the broader healthcare team. Today we're gonna talk about how educators can recognize these challenges and respond constructively in ways that support learners strengthen professionalism and maintain psychological safety in our learning environments and across our entire medical center to help guide us through this conversation. I'm joined today by my colleague, Dr. Rob Martinez. To start, Rob, could you introduce yourself and tell us a little bit about your role in our teaching programs and how does your work connect with the larger medical center i'm Robert Martinez. I'm our associate program director for our family medicine residency. But also I come as a Chicano physician With all that, that brings in my training as well, and it's led me to take the equity, inclusion and diversity role for our residency and also for our campus where I could help make sure that equity is, and all that we do for our patient care, our patient interactions, and our colleague interactions. Awesome. I thought you'd be the right person to talk to for this. Let's begin with the issue of bias in clinical teaching and evaluation.'cause this is something that can be difficult to recognize in real time. Bias in clinical evaluation is often subtle. Can you think and give us some examples of bias that can show up in student or resident evaluations? Absolutely. So, the, one of the reasons why it's so hard is because bias that we have is so implicit. It's just ingrained in us with how we've learned to navigate this world that we live in. Our brain, the way it works is we create shortcuts. That are easy for us to learn to get to a certain end goal. Those shortcuts are great because that's what has helped us get to where we are now. It's helped us how we learn and those shortcuts are based on how we interact in, in, with this society. And it's been so heavily influenced by societal factors. So what does that mean? It doesn't mean that all of us are bad. It just means we all have our brains work how they're supposed to work, and we have these shortcuts. And sometimes these shortcuts are laid in with a lot of bias. It can show up, especially for us educators. It can show up how a resident or how a learner behaves or acts. And we may view that in a lens that we have to say that, on my lens, this is seen as a negative without looking more to. What is it? What are the factors that are interacting with that? One of the common things that we do now, one of the common examples we have is the generational change between, millennials. I don't know all the names of the different communities, but there's a big gap now that I am older. Yeah, I am, unfortunately the old Gen X, so there is a lot of generation. You and me, both. You and me both. So let me just go and say, am I a crusty Gen X? Yes, I am, but I'm also an inclusive crustiness. So, so how would that show up? One of the ways that it shows up in looking at evaluations, a lot of times we say, this learner is distracted. This learner is lazy. This learner does not get the flow of how things work because. The way we look at that is our lens, uh, the bias that we have. One of the biases we have is expedience bias, meaning what we know is. All that we need to know to look at a situation, and that's what we do a lot of, that's how one of the things that we default on, I have enough information and I have enough experience that I know what's happening in front of me. So this learner that is behaving differently than I would clearly is not going by what I think is right. So they are clearly lazy or they don't wanna work. That is way more common than we would like. And it takes us, the evaluators to say, these are my biases. How do I make sure that these biases are not getting in the way and I'm getting, asking all the questions that I need to ask to collect the information that I need to get a more, a better evaluation of this resident. So when a resident gives me a jumbled HPI, and they're, I feel like they're all over the place, that's because my brain works in a certain way. Then their brain. It doesn't mean that their brain is wrong, their brain is actually has all the information that it needs, but it's presented in a different way. That was not hammered into me for medical training, but we still get to the same results of a phenomenal patient care. So if I were to use my bias and say, clearly this resident doesn't know what they're doing, their HPI is all over the place and. Does it matter that the assessment of plan is right? Look at this HPI. If I were to step back and say, okay, that's how my HPA is going, but how do I fully listen? How do I make sure I'm asking the right questions that this resident knows the medical knowledge while they're giving the HPI? Those are the questions that we need to ask as educators to make sure that we are evaluating our residents correctly, to make sure that they do have what is needed to go on to the next stage. And so can you expand a little bit more on some strategies that faculty can use to separate sort of objective observation from interpretation? Mm-hmm. When we're evaluating our learners? Absolutely. So one of the ways that I always tell people is. Let's be accepting that we all have bias. It doesn't mean we're bad, doesn't mean we're good. Just how the medical training is. So when something comes up and you realize, oh, this is really triggering something to me, you know what? That's okay. It's not, you're not a bad person for, for having something come up based on the way you view the world and. When you see a resident do something, it is highly important that we look at what is the behavior that's happening. Let's not interpret what we think the resident is doing or thinking, or what their upbringing is that led them to this. That is not gonna be helpful. What we wanna look at is what are the specific behaviors that they're doing, and what do those behaviors mean? If this resident is jumping from one. I'm going back to the, the case for, um, residents presentation because I think that's kind of a hot topic for faculty is, is presentations. Mm-hmm. Is looking at, okay, this resident goes from problem A and then jumps down to exam findings specifically for problem A then goes to assessment and plan, then he jumped back to problem B and went to the exam finding specific. So that's feeling in our brains jumbled. Bringing up the behaviors of, I noticed that in the HPI, you gave me this complaints and you did not give me the complaints of the rest of the exams. Can you explain more how that works? That is going to allow us to understand how the brain is working and so let we focus on specific behaviors and not our interpretations of what those mean.'cause that leads to emotional problems. For the faculty and the learner. Mm-hmm. That doesn't improve the behavior or the outcomes of the patient care? Yeah, I mean, I think this happens all the time. Um, we're both on the, the Clinical Competency Committee where we evaluate residents and, you know, how many times do we see evaluations on the same resident where one person says. The residents seem, I'm confident, not well prepared. And then another faculty says, whoa. They were super thoughtful, careful, thorough. And so I imagine that there's a lot of potential interpretation going on here. Correct. Yeah. That makes it really difficult to know which one is true or not true, right? Correct. Correct. Makes it very difficult to figure out how. This resident is doing when you have conflicting evaluations. Yeah. And you know, again, we're all human. So like you said, we're all bringing baggage into, maybe baggage is a strong word, but we're, you know, we're all bringing our the breadth of our clinical experiences into each one of these interactions. And so yeah, that's really super helpful, I think to take that step back and. You know, really think about how you as faculty might be approaching that evaluation. Absolutely. Yes. Same resident is showing up differently because of how we interpret it, I think is what I'm trying to say. Yeah. So let's segment for a second into what microaggressions look like.'cause that's another sort of hot topic. In, not only medical education, but also in just clinical interactions that are, potentially happening more and more, or we're just more aware of'em. Right. Hard, hard to know. Right. So, there's a lot of scenarios I can think of where, there's potential for interpretation of microaggressions between faculty and learners, between members of a larger healthcare team, between patients and learners. So can you give some examples of things that you've either experienced. Yourself or that you've seen? With our learners. Similar to bias that we all have, where the bias is can, is subconscious, where it just comes out because that's the basis of how we seen our experience in this world. Microaggressions are similar in that they are unconscious. The person didn't set out to say, I'm gonna hurt you today. Mm-hmm. I think it's very important to tease out that the word microaggressions, even though micro is in it, means small, does not in any way mean that the impact of it or the harm of it is not great. So we need to tease those two out. Microaggressions. The term was coined because it is different than outright blatant racism. Outright blatant discrimination. Saying, I'm gonna put a sign up in my office that says this group of people can't come in. That is blatant. Microaggressions are the small, subconscious or unconscious ways that we speak that is heavy with the biases that we bring. And some, a lot of those biases come from racism, discrimination, as well. Mm-hmm. So we do this and it, it affects all realms. It's not just. Racism, ethnicity. It also has to do with a person's gender. Mm-hmm. Has to do with the person's how they present themselves. It has to do with a person how they speak as well. You'll notice people with certain accents get a lot of it. So just an example of how it fits into a lot of different arenas, not just a person's race or ethnicity. So a lot of these can lead to invalidating a person's opinion. A lot of these can lead to feelings of I am being othered, or I am being outed. Because I'm not like this person. So that's how these microaggressions show up and they show up in many ways by saying, certain examples when you come in and I present, well, oh well you are very well spoken for a person of color, or for a person whose English is not the first language, that may be very triggering. Because why would you have to focus on my language? I'm here talking to you about medicine and my smarts on how to treat you, but you're focusing on how I speak. And, and because that has been such a big historical problem that people of color have also asking things, that I've heard a lot as well, as well as, oh, you don't look like a physician. Okay, great. What is a physician supposed to look like? Because mm-hmm. I've gone through the training, but clearly. My medical expertise does not make you feel that I'm a physician. What is that coming from? And that's where the things where they may, they may be even trying to uplift you, saying, great, you are, I don't know, your experiences have made you better than the other physicians I've seen, but when it comes out as you don't look like a physician. Mm-hmm. Theres a lot of historical context that comes with that. So that could be seen as microaggressions as well. And again, a lot of these people aren't saying, Hey, I want to harm you. It's just this is where the bias comes out. And they speak because, you know, Lord knows a lot if the country speaks without thinking and that's where the, the harm comes in. So microaggressions are those subconscious words, phrases, ideas that come out that we don't think about, but are heavily based upon the biases that we carry, in our life. Thinking back through this, there's probably been many experiences that, I've even had personally or as faculty. And it's often upon reflection later that I sort of realize it and then I beat myself up for not having necessarily addressed it. At the time. So let's talk specifically about learners for a second. What do you think the responsibility is of faculty to have that awareness and or what does that responsibility look like in terms of addressing that, that perception that, somebody might have been wronged in some way. Right. Or experienced a microaggression, first, if a faculty does get to that point where they realize, oh, I might've done this, that is fantastic. That is such a huge step, and I would applaud that faculty for one, having the ability to recognize it, and two. Having the confidence to say, Hey, I, I made a mistake. The next step would be how do I fix it? Um, I would absolutely champion anyone to say, to go to the resident and speak with them to say, I may have done something I want to discuss with you, just to see how it impacted you. Because you'd be very surprised to say, to see that maybe the resident was like, oh no, that actually that. I didn't take it as that at all. Or they may say, yes, thank you for bringing that up. And that actually starts to strengthen the bonds and the relationship that we have in training. Because what we wanna show is we are not perfect. Residency training is not perfect. Residency training is still has so much harm to it. But if we know that we can talk about it together, that strengthens the relationship a million times more. Mm-hmm. So being able to go be open and talk about it, to say, I may have made a mistake. I'd like to get your opinion on it because I'd like to improve, or I'd like to see what I can do to repair this relationship. The second half of that is, what about the people who, us faculty who don't know? That we've done something. Mm-hmm. What about when a resident comes to you and say, when you said this, this made me feel this way. That's where the kind of, that dance gets a little bit tougher because one, it takes the faculty understanding that, hey, they done something wrong. Even if they didn't mean to. One of the, examples that one of my colleagues give who's really adept in this as well, is to say, you know, if you're dancing with somebody and you step on their toe, they didn't mean to step on your toe. Mm-hmm. But you still hurt their toe. That person is still in pain. So whether you meant to step out in or not their pain. So what's up to us? Who was the cause of it to recognize? That, yes, you can look at the intent and say, I didn't mean to do that, but it's a million times more important to say, but the impact of what I did or said or didn't say, I need to recognize that and how do I apologize for that? Not to say that I am wrong and I'm a horrible person, but how do I apologize? Because that is the thread that we need to tie together those both sides to make that repair in the relationship so that we can learn. The resident can learn and that we can get stronger. So yeah, what I mean, what you're really talking about is creating a, a psychologically safe environment so that both faculty and residents feel comfortable being able to say, Hey, did I screw up in some way? Because I wanna learn. To be better. So kind of a, a follow up question on that. So what do you think is the best approach if you're in an exam room and a patient says something that I mean, I guess it doesn't really matter if it's blatantly racist or it's a, you know, more of a insinuation or, or microaggression as faculty. Do you think that's something you should address right then and there in the moment, or do you think that might be interpreted by the resident as you're speaking for them? And not giving them the chance to respond, so mm-hmm. How do you maneuver those kind of more tricky situations, especially with patients? Yeah. Yeah. In a room, how would you it is tough. It's a tough one. Yeah. Because one, you need to make the space optimal for healing for the patient and for the, the physicians. One. One of the, I'm gonna, I'm gonna take a step back here a bit. One of the things that I see with how we're taught in the healthcare system is to look at us. Physicians are the ones who deliver the healing, and that is how the exchange goes. It goes from us to them, and then they leave and they get better. The way I have it is that we are in there as a team and I'm offering healing to you. You patient offer healing to me as well in whatever form that's gonna look. So when a patient comes in and we have that interaction, it's important to know that just as much as we can heal them and they can heal us, we can heal harm them, and they can harm us as well. Mm-hmm. This is where the, the microaggressions or the, yeah, let's just say the microaggressions come in from the patients when it's coming directed at us, and especially directed at our learners. It's important for us to say something. It doesn't have to be a full correction and explanation as to why that patient and what they said was harmful, but it's important for us to stop it and that could just be simply doing that. I just wanna pause here for a second because I don't want us to concentrate on what was just said. I'd like to go back to the reason why you're here and the symptoms. Tell me how I can deal with that. That is the bare minimum to say, let's stop it. Let's focus on the medicine. That allows us to say that your behavior, your actions are not gonna to be tolerated here. And it tells the learners and the patient as well that there's a certain expectation in this arena of healing when you come in to be seen. And that is understood and those that don't understand it, okay. It's gonna take definitely more work. But I just wanted to give the bare minimum of saying, first thing you do is one, recognize the microaggression. Two, interrupt it just by saying let's stop. I'm looking at the action that was directly in front of me. I recognize that I'm stopping it and we're pivoting to going back to why you're here. Makes sense. If I am a resident listening to this. Podcast and I am the object of a microaggression. Are there some things that I might be able to say? Would, would you as a resident just say, you know, the same thing you just said, which is let's just focus on your reason for being here. Is there anything else a resident can or should say at that point? Absolutely. If a resident does speak up, we should be there to support. We're not gonna be there to cut off and say, oh, nope. What my resident means to say what we should do is just echo their sentiments of what they're saying against the microaggression they felt. But how do we create that environment so that they can have that confidence? That's where the work comes in before, during addressing the microaggressions and then after as well. It is important to check in to say, this is what I saw.. How do you interpret what just happened? And then after that, what would you like to see done? What could I do to make this better? So that would be important to allow that, safe space or that brave space for residents to be able to speak up and say, I do feel confident enough to say this. This is what I would like to happen. What would you say to a learner that says that I'm worried that if I speak up, it may reflect negatively on my evaluation? That is absolutely one of the power differences that we have. We want learners to speak up, but in their mind, we are the ones that hold the power to say they're gonna pass this rotation or they're not So it's very scary. I think it's very important for us as faculty to realize that's how we're viewed. It's obviously not correct, but the feeling may be that we hold the power to not have them pass a rotation. So this may be a reason why nobody speaks up, why somebody's just gonna do exactly what's told and not say a word and allow a lot of the harm to continue. So one of the ways that we can make it. More open is in the beginning when the resident's coming in on the rotations. Checking into making sure we are being blatantly obvious about let's have a space that we can talk about this. We can't change other people's behavior. But we can. Have an environment where you and I view and me resident, you and me medical student, or even if it's a high school student shadowing for example, that we can have a space where we can talk about it and learn and grow. Yeah, that's great. And I think, being part of, of the residency and kind of seeing its growth since it started,. We've put a lot of work into. Recognizing this and addressing it and trying to put some systems in place. What would you say in your role for the larger medical center, what kind of systems are in place or that you're looking to put in place for these situations that happen outside of the residency Great question.'cause one of the other roles that I have is the lead for the equity, inclusion diversity for the campus. And it is a big lift because we are navigating people from different education levels, different experiences with the patients different upbringings, different financial constraints, all the things that could make a workplace stressful. That's where we have this big. Boiling pot. Boiling pot, yeah. That can easily just, explode. We have a curriculum that we use to talk specifically about microaggressions. I had just given one on, on microaggressions and how to respond, but we talk about bias and implicit bias and how we all are affected by it and how it comes in, in the workplace. We bring up how do we be upstanders and allies in situations where somebody needs to speak up. And we also talk about how do we. Make our environment inclusive. So we're doing all of that for our campus with these, I was gonna say lectures, but not really lectures.\ I give a, an overview. We go into some depth, but I leave a lot of time at the end to ask questions and talk about certain situations. We are also looking. At how do we empower our departments? Those that are not feeling as inclusive, how do we take those good examples from the good, the departments that score really well, and how do we make sure that the other departments that aren't scoring as well are feeling very inclusive and what do those look like? We're also making sure that we are offering a lot of different opportunities for people with many different backgrounds to be involved in. Do we have a lot of work to do? Absolutely one of the things we need to do is we need to talk about representation as well, which our PIC has been very open and honest and wanting to work to increase the diversity of leadership as well, and is making actual steps to do just that. How do we make sure that we have a campus that if something happens that we can talk about it? That we can repair what happened as opposed to most workplaces, which is punitive and you did something bad to me. I'm going to make sure that you are punished. How do we change it so that our campuses, you've done something bad to me. How can I understand what I've done to you and so that we can make our relationship better? That's a huge culture change, which is gonna take a lot of time, but it's the, the small steps that we're doing to work on that. Yeah. It's not only a culture change, it's fraught with political challenges as well. Right. So, correct. How, how can an individual an educator, a learner, kind of steer away from getting into a discussion about politics? And instead sort of ground the discussion in. Patient care, professionalism. Are there some statements that you could give us? Some strategies where we could, really steer a conversation that's heading in the wrong direction where nobody is gonna walk away from that conversation feeling very good into a place where we could calm the waters a little bit. Yeah. I like calming the waters. We may never see eye to eye or understand each other.. So I've had people, especially patients as well, that bring a lot of stuff that are pushed by a lot of political agendas and how do we focus on. What is the actual data in front of us without trying to lecture somebody? So one of the examples I give when I was, working in the hospital, I had a patient who was admitted for COPD exacerbation. The big discussion that he wanted to have was about this whole environmental thing and how it's such a leftist agenda to make everybody go green. And I was like, I don't have opinion about who is pushing what or what the idea behind it is. What I understand is this about the environment and how it's directly affecting your lungs. You Yeah. And you. Exactly. So that went to the, where it focused more on what is actually in front of us. How it's directly affecting your care and this is what I'm gonna do.'cause I care so much about you, this is what I wanna do to help you out. So that's one of the ways is it, it is not in any way avoidance. It is not in any way trying to convince, and that person may say, yeah, no, you're doctor, you're a quack. What are you talking about? That's okay. It's important to understand that the healing of the person is based upon what it is they want and we have to accept that sometimes. Yeah. No, it's, it has unfortunately become so much more pervasive in our relationships with patients. I mean, as a pediatrician, it happens all it's a time with vaccines. Yeah, it is really hard to steer the conversation away from the fact that vaccines have gotten so political and instead, come back and focus on, we're talking about you today. Yeah. We're talking about your care. Any, any other suggestions you can think of? It made me think of a story about vaccines. I had a, probably a college age student. Come in for a first time physical and then brought up, vaccines as well i think he directly asked, why do you push all these vaccines? And I, and I stood back for a second and I asked, as a family practice physician, you're asking me. Why I am trying to prevent future illnesses. Is that what you're asking me? And it made him pause and think, okay, he may still have left with, yeah, these guys are just pushing stuff. But I reframed it in a way of, i'm a physician looking to prevent vaccines, prevent eating well, prevents exercising, prevents a lot of things. Stop eating processed foods, prevents trying to reframe it that way. And it's tough because that was probably my first visit of the afternoon. So I was probably well fed. Rested in a clear mind. Versus if that was the last visit of the day where I'm. An hour behind. Would I have been that way? Probably not. But that's where we should give ourselves grace as physicians to say, sometimes you can. Sometimes you can't. Yeah. Absolutely. Can you really quickly just comment on upstander versus bystander? Sure. Um, and how that might look. In clinical scenarios. So I think everybody understands bystander. Those are the observers that's watching everything go on. An upstander is going to recognize what's going on and do something to interrupt that flow of activity. That's what an upstander will do. And upstander is also a spectrum. Just like I mentioned before. Sometimes you just need to step in and just stop the microaggression. From happening. Upstander is the same. Upstander is one is going to interrupt, but depending on the relationship with the person receiving the microaggression, the understanding, the relationship that the UP center has with the person delivering the microaggression, being able to navigate all of those little intricacies to be able to. Do more if it's possible or if it's called for, to say, I'm also gonna help educate the source. I'm going to help repair the person who was the res recipient of it, and how do I, if not being the one speaking up for that person, how do I support that person to be able to speak up? So it's, it's very. Delicate. It's very nuanced. So to say. Upstander does this Well, it is yes. And it's a huge spectrum of what a upstander can do because what we want is to be able to help, but we don't want to come in and be the savior because that is just as harmful. So before, before wrapping up, and I so appreciate your time, this has been. This has been amazing. If everyone listening to this podcast were to make one change in how they teach, how they, evaluate learners, how they interact with learners and patients, or just interact with each other, what would that one change be that would make the biggest difference, do you think? Right. I would want all of us to understand how much we are connected to each other. So that when something comes up and you're feeling a response, it's easy to look at the PO when you get a response. That's positive. Everybody runs to that. Yes. I love that. When you get a response that's negative, how can you take a pause to reflect on what is that thought coming up so that you can start to ask the questions about yourself, which allows you clarity to start to ask questions about the situation so you can make sure that that connection remains so that we can repair whatever relationship we have or strengthen whatever relationship we have. I don't want to use repair all the time because sometimes the relationship is just needs that strengthening. So all of what we carry as faculty and learners is not a negative. Even if it has negative impact, understand that that is just part of your learning. We're not bad, we're not evil have grace in knowing that we're gonna make mistakes and be open to learning and asking the questions of yourself, of why did I get to this point and how do I make myself better? Your learners will absolutely love it. It's hard work, but your healing that you're gonna do for yourself, healing is gonna be a magnificent journey. Thank you so much for joining me today and sharing your insights on such an important topic. I think these conversations are so essential for building learning environments, for building an inclusive campus like you talked about, where everybody feels supported and respected. So thank you for all that you do. I appreciate you. I hope and believe others appreciate the work that you're doing and hopefully this will open some interest among people to attend some of your lecture series absolutely. Thank you for having me. And it was. Wonderful. Talking about this topic. I love talk, talking about it. That's awesome. Thank you. This is life and practice.