 was published in JAMA in 2019 by Vander wheel and colleagues that from the Harvard School of Public Health and their flourishing index has a six key domains for reimagining health. And those domains were originally focused primarily on thinking about health for patients and populations. But we cannot adequately think about health for patients and populations unless we also think about those delivering health and healthcare within the overall system. And so I just want to invite you to think about the components of that index as I go through my comments. So those six domains are happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtues, social relationships and then financial and material security. So with that index in mind, let me move forward and share an overview of the three key areas that I intend to cover in my remarks today. The first is to provide an overview of gender equity in medical education writ large, followed by three case studies that come directly from the clinical learning environment. And then finally to conclude with frameworks and I will share two frameworks to support flourishing related to gender equity in medical education. So let me begin with this overview of gender equity in medical education. And I want to make two particular comments about gender equity in medical education. And the first is that in thinking about what I might say to you today, I obviously had a lot of opportunity to think about my own career in medicine which has been very strongly and unbelievably aided through mentorship largely of men who helped me along the way. But on continued reflection, I'm also well aware that our profession of medicine has embraced science and technology in a way that has transformed health and healthcare in America. And I think about the kinds of discoveries related to the gene for cystic fibrosis or the ways in which the human genome has been decoded for us. Or in fact, the ways in which immune therapy has led to unbelievable progress in treating our patients with cancer. And I could go on and on with those scientific advances that every day our patients and our systems and our population are benefiting from. So what is it about our profession that has allowed us to adapt and implement scientific advances at breakneck speed but we've not been able to do the same thing related to human capital. And we've not been able to do the same thing related to our training programs. That's something I think about a lot and I hope I'm going to invite all of you to help me change the world around those things because we've known about these issues for a very, very long time as a profession but yet we haven't seen the same kind of uptake that we have related to our scientific advances and there must be some things that we could do differently to affect change. The second thing I wanna say is that the references that I'm using for today's talk really speak of gender as a binary and I think all of us know that gender is not so simple, it's not a binary but I am going to be referring to it largely as a binary because that's where largely the published literature has existed for a very, very long time but also because I did spend so many years on this campus, I have the personal relationships with students and faculty who have transitioned and I don't want to unfairly misrepresent any particular individual in any of the comments that I might make. So I wanted to just offer a disclaimer about referring to gender equity as a binary without the explicit statement that it's obviously much more complicated than that. So to get started, let me just provide a broad overview of a few of the issues related to gender in medical education and this is not meant to be comprehensive but there's the issues that I will focus my comments on today. So first is that we clearly have some disparities and professional opportunities. I'll share a snapshot about that. We have higher levels of mistreatment that fall along gender lines. We also have an association with bias and grading assessment and content of narrative evaluations and we have a clear impact on childbearing and child rearing that we've known about for a very long time and have made some but very, very little progress related to that. So what about the disparities and professional opportunities? This really is a snapshot from the Association of American Medical Colleges database from 2023 showing on the left hand side of your screen applicants to medical school by gender, men in blue bars and women in the orange bars and then matriculants by gender on the right side of your screen and this just really gives us a snapshot of the last decade and you can see that we have achieved diversity by gender in our profession. However, the thing that's not obvious from this slide is that this diversity in fact was achieved on this campus in the mid 90s. And I remember being the internal medicine residency program director at that time when the Chicago Tribune and many different media outlets in Chicago were on this campus interviewing our students and then Dean of students Norma Wagner about the University of Chicago achieving for the very first time an equal number of women and men in our entering class in the Pritzker School of Medicine. Again, that was 1990s not depicted on this slide. So the point is as a profession we have achieved diversity by gender in medical education but we have not achieved equity with this wonderful diversity which we have attained. I think you've seen this slide before in this series because one of the authors is our very own Dr. Vinnie Aurora and this is a very important slide that shows the pay disparities. Man represented here in green, the women in gold, the difference by the orange bar and over the course of a career in medicine all aggregated together women are in general going to earn $2 million less than our male colleagues. And then of course this disparity is greater for the surgical professions but nonetheless it's a very large number however we cut this data. We see disparities in promotion in the academic ranks and this is a paper that was published in the New England Journal in 2020 and what we see is that the disparity in promotion between men and women occurs both at the associate professor level and at the professor level. And this is a really well done and quite elegant paper controlling for a number of different variables and the disparity persisted throughout the many different ways in which the authors analyzed their data. So over a 35 year career women were less likely to be promoted and there was no apparent narrowing in that gap over time. I don't know if you've seen this slide before but it's from the Association of American Medical Colleges database and I think it makes a very powerful visual point about women at leadership levels in medicine and how that pipeline gets progressively very narrow as we move from medical school applicants to those who graduate from medical school, those who become residents and then faculty and then look what happens at the highest levels in terms of the percentage of women represented as division chiefs, attain full professor status, attain roles as senior associate deans and very, very small numbers here for department chairs and deans of medical schools. We also have gender disparities and publications and there are a lot of different ways that this has been illuminated in the literature but I chose pediatrics as the discipline to share with you today in large measure because it is a discipline that is heavily populated by women as faculty members and even in that field you see the first authors of various publications by journal type on the left-hand side of your screen, men in the darker bars, women in the lighter bars and on the right-hand side of your screen by article category. And so this was a surprising finding in some ways but obviously a durable finding in terms of the number of journals and the types of articles that were analyzed by these authors. We also know that there are gender disparities in work that gets done in caring for patients and in doing the teaching to train the next generation that is not renumerated. And so one of those examples is narrative feedback to learners and what you see in this study by Montanian colleagues is that male faculty compared to women faculty were much more likely in the assessment forms that they filled out on their learners to provide nonspecific comments or no comments at all. And the reason that this is important is that accrediting agencies are looking specifically for narrative feedback. That's one important thing, but students themselves and residents themselves are looking to improve their performance. And when there isn't narrative feedback it makes it much more difficult to try to understand what the performance level is and how to help the student or resident perform in a more effective way. The second example here is the workload undertaken by the Electronic Health Record and Rittenberg and colleagues. I think published a really incredible paper about women primary care providers spending 28% more time in the EHR in basket and 22% more time on notes than their male colleagues. But in large part that's because they're receiving almost a quarter more messages from staff and from patients when compared with their male colleagues. So no wonder they're spending more time in the Electronic Health Record they have a lot more activity coming into the inbox. And of course they are not being compensated for that work. Now, I don't know if you've seen this paper before but I wanna point out that this paper is has the first author, a graduate of this medical school Teosie Adesie Oyi who graduated in 2012 and is in a surgery position at MD Anderson today and she started an online community for physician mothers and this online community was invited to share their experiences as mothers in medicine. And from that survey, which she shared with the group a total of nearly 6,000 of the respondents reported discrimination and those fell into various categories which you see on this slide. Specifically my pay or benefits were not equal to my peers and those who experienced discrimination as mothers are in the lighter gray bar, those who did not experience discrimination in the white bar. I was not fairly considered for a promotion or senior management. I was treated with this respect by nursing or other support staff and obviously that has the highest rating for discrimination. I was held to a higher standard of performance than my peers and I was not included in administrative decision-making. So multiple different snapshots for the ways in which the physician mothers were feeling discriminated against. Another part of that survey was a question. What are the three workplace changes that you consider most important? And these are the three things that group asked for. A more flexible weekday schedule, a higher salary and a longer paid maternity leave. Okay, let's turn to the second major category that I'd like to cover today and that's case studies from the learning environment. And as I've already signaled, these cases are based on incidents which occurred while I was here at the University of Chicago. I have changed some key details so that I'm protecting the privacy of the individuals involved. Many of you have seen me use this framework in prior presentations and it's a framework that's actually fairly old written by Lauren DeLos and colleagues and educational psychologist where he plots challenges on the scale from low to high against support levels from low to high. And you see in the lower left hand quadrant that when challenge is low and support is low, stasis occurs for the adult learner. When challenge is high and support is low, retreat occurs for the adult learner. When challenge is low and support is really high, the learner generally has confirmation that what they're doing is just fine and appropriate. When challenge is high and support is high, that is where growth occurs and that's where I hope we all aim to be working and living in that space of growth. But obviously things can go wrong and there are always things that we can do better. So it's in that spirit that I present these cases. So the first case involves Jane Doe, a third year medical student on her surgery clerkship who was doing her two week rotation in neurology. The attendings and residents were all men and the other third year student rotating with her was also a man. In the outpatient clinic, she was routinely assigned only to the women patients because quote, patients will be more comfortable. However, her colleague medical student received patient assignments of both genders. In the operating room one day, Jane was asked to place a Foley catheter and as she was performing the procedure under supervision, the resident called out, hold it like you mean it. And then those in the operating room that day erupted in laughter. So following this episode, Jane met with the surgery clerkship director to share that she was feeling as if she'd been denied some patient care opportunities during this urology experience. And she considered what had happened to her in the operating room that day, a really obviously uncomfortable and hostile kind of experience. So the question for all of us to think about is how should the clerkship director for surgery respond to this situation? I also wanna say that I could have chosen a very large number of cases where men doing their obstetrics and gynecology rotation had similar kinds of thematic experiences. Okay, so for those of you who do not know when students graduate from medical school all across the country, they are invited to complete a graduation questionnaire where they report on a whole range of experiences that they had in medical school. And then after the students graduate, the school receives in aggregated fashion feedback on the responses of their students. And they also get to see the school gets to see the national benchmark related to each individual question. So among the questions on the annual graduation questionnaire, ask students whether or not they felt like they were denied opportunities for training based on their gender, had they been subjected to sexist remarks or names and do they think they received lower evaluations or grades solely because of gender rather than performance? So we and other medical schools regularly have the opportunity to see our performance on those various questions. And what you see here is a paper by Hill and colleagues published in JAMA where we see the national aggregates by women and men, women in the orange bars, men in the blue on their reports of one episode of mistreatment, two or more episodes, public humiliation, subject to sexist remarks or names, lower evaluations, denied opportunities for training and unwanted sexual advances. And in every one of these categories, obviously, women are reporting these events at much higher rates than their male colleagues. There's also a very important component that is not displayed on that particular data set. And that's the component of intersectionality where underrepresented students who also happened to be from underrepresented in medicine groups had the highest levels of racial and ethnic discrimination being reported. Asian underrepresented minority, multiracial and LGBTQ students reported a higher level of mistreatment than male white heterosexual students. There is further work being done by this group at Yale on this topic and the Macy Foundation actually is supporting this work in follow-up grants. So you will hear more to come. So let's go back to our students. So Jane Doe had this experience during her two-week rotation on urology. So how should that clerkship director respond given everything that I've shared? So a stasis response might be, well, I'll speak to the surgeons, but it was really just a bad joke. And why are you worried about your grade? The attending saw you place one fully, it was fine. Nurses do it all the time. It's really not that complicated. Low support, low challenge. Retreating from that state might be you can't take a joke, lighten up. Remember patients have the right to be comfortable. If you missed out, no big deal. You weren't going into urology anyway. Some of these are actually kind of verbatim quotes just so you know. Or to confirm how Jane might be feeling. Oh, so sorry that that was said, we've all been there, you'll get over it. Don't worry about the patients. I checked with the attending. He said, you're doing well. The more ideal response might be, I will speak with the program director and you're attending. Your experience in the operating room was unacceptable. I'll make sure that you have time in our sim lab to practice skills if you feel that you need more educational opportunities. So again, I'm not aiming for perfection here, just aiming to help all of us think of ways that we might be more effective and do better. So let's turn to the second case. And this is a case of gender bias and assessment. Mary Smith is a second year emergency medicine resident. She aspires to become a chief resident. She knows that there are specific attributes associated with being chosen for leadership, including decisiveness and confidence. Recent evaluations have discordant narrative feedback around her autonomy and assertiveness. And indicate that she's lagging behind in meeting her milestones. Mary actually compares notes with the other residents. We all know that happens all the time. It's one of the ways residents survive, checking in with one another. And what she hears is that several other women are feeling similarly and reporting that they also are receiving conflicting feedback in their narrative evaluations. However, she's not hearing that from her colleagues who are men. So they decide that they're going to ask the program director, is this real? Does the program director have a perspective about this? So what do we know? And once again, part of what we know came right from this institution. I actually remember when this was presented at Medical Education Day, long ago, Vinny Arora is the senior author and it was our own student who took a look at the feedback from attending physicians in terms of the milestone ratings that they were awarding to residents in emergency medicine. And what you see is residents in the PGY one year, men and women basically earning milestone ratings at the same rate essentially. There's a little bit of variation there. But by the PGY three year, there are very significant differences. And those differences are such that men are achieving their milestone ratings. So if you get all the way to the right hand side of that scale, milestone level five, being able to practice without supervision, men are achieving those milestone ratings at a faster rate. And the aggregation of this data set shows that it adds up to about three or four months of training indicating that men could finish three or four months earlier, women have to extend their training three or four months. This is a really important paper and very important findings. There's another paper from the emergency medicine literature which these authors looked at the narrative feedback in particular. And what you see displayed on this particular graphic is the times when the qualitative assessment of narrative feedback for men was in aggregate five percent or more greater than for women. And likewise, when the commentary was five percent or more influencing the women's performance, you see it plotted here in the gold bars. And so the kinds of things that were favoring men are all those domains that you see listed on the left hand side of that graph, professionalism, provider communication, differential diagnoses, critical thinking. The women were more commonly referred to in their narrative comments about their adaptability, their confidence level, their assertiveness with treatment and more commonly rated below the performance of men. So I think there are a lot of very important observations by this qualitative data that should help us look very explicitly at our systems of assessment and do better. So what happened to Mary and her colleagues in emergency medicine? How should the program director respond when the women residents ask this question? The program director could say, well, we're using the forms that come from the American Board of Emergency Medicine and the ACGME, they're the milestones forms. So I'm sure everything's fair. Don't worry about the faculty feedback. This is the best program in the country and you're getting a great education. The retreat might be, oh, don't be so sensitive. The faculty are doing important work and they don't need your criticism. To confirm their experience, the program director could say, listen, the milestone ratings are meaningless. Don't play such close attention to them. You're all doing great. Or, you know what? This is important feedback. We will look at our assessment data and if we discover bias, we will provide faculty development and come up with a fair and constructive way forward. I'm gonna have the faculty ask you specifically what kind of feedback you'd like to receive so that they can pay attention to areas that you'd like to work on and develop further. We clearly know there is a lot of bias in our assessment systems and so I think this is another example of where we can do much, much better as a profession. So let's turn to the third and final case and that is maternity leave. So Molly Jones is in the first year of a cardiovascular disease fellowship program, a field in which only 21% of fellows in America today are women and Molly thinks she'd like to be an interventional cardiologist. After many years of trying and rounds of in vitro fertilization, she becomes pregnant with her first child. During her pregnancy, she develops preterm labor and is assigned to bed rust for the last three months prior to delivery and a six-week maternity leave. Her colleagues in the fellowship program are happy for her but resent the additional burden of work. They worry that even when she comes back, they will continue to carry a disproportionate load. Okay, this is unfortunately a really common kind of issue and this is a paper from Stence and colleagues which I think makes it important visual description of the ways in which our profession makes it really hard for women who wish to be mothers. And you can see that depicted here by the age at which people on average graduate from medical school when they complete their training, their first attempt at conception, age at first pregnancy, compared with the general population in the black bar and then the infertility diagnosis. And once again, Vinny Aurora and colleagues published a very important paper about what are some of the strategic ways that we could address these issues? And one is fertility related education. Certainly wasn't talked about historically in this profession, it was a one-on-one thing but not a general conversation. Health insurance, big, big issue for all Americans and in particular for those training in our profession and then overall support. So I also wanna share an anecdote, it's a really powerful one and one that has stayed with me for my entire career and that is that for many years I was a member of the American Board of Internal Medicine and I sat on that board with one other woman at a time when we were presented with a proposal by the staff of the American Board of Internal Medicine to cancel maternity leave for all women. And on that particular day, I went beyond the wire arguing for why that was such a bad idea and why that would set our profession and our discipline back decades. As I said, there was one other woman in the room with me that day and unfortunately our argument lost. And it lost on the premise that as you know, internal medicine and pediatrics offer combined training. At that time, in the early 2000s, internal medicine had a provision for maternity leave. Pediatrics did not have a provision for maternity leave and isn't that ironic? Pediatrics didn't have a provision for maternity leave but they didn't. And so those who led the ABIM at that time felt like we were diluting the American public by saying that everyone training in internal medicine had 36 months of training when in fact, if you had a maternity leave, you would not technically meet that requirement. And so that day in that board room, maternity leave was canceled. So I could write a book about all the arguments I lost and that was one. And it obviously stuck with me for a very long time. But the thing I'm inviting all of us to mobilize around is why has it taken so long for us to change what is pretty straightforward kinds of things? Like how can you expect to be in internal medicine in your late 20s and 30s or later and not have a provision for a maternity leave without extending your training? Well, the American Board of Medical Specialties which is composed of all the specialty boards, internal medicine, pediatrics, obstetrics, and gynecology, radiology, you name it, if a certificate is awarded, they're a member of the American Board of Medical Specialties. And so what you see here is that that organization will now allow for a minimum of six weeks away one time during training for the purposes of parental caregiver or medical leave without exhausting your vacation or sick leave time and without requiring an extension of your 36 months of training in the case of internal medicine. Now, when do you think the ABMS made that rule? Yeah, yeah, July 2021. Amazing, just amazing to me. So I think you know how I feel about that. Okay, so back to Molly Jones. This is a really challenging issue and because of Molly being in her first year of fellowship, she wants to be an interventional cardiologist. Fellowships are really small programs, really small. So you have very little latitude as a program director. So how should the fellowship program director respond and support Mary in this situation? You see here that I do not consider this situation one of low challenge. I think this is a high challenge situation. So we're not even gonna consider the quadrants of low challenge. So if we're going to accept that this is high challenge and with low support, the program director could say, are you sure you wanna be an interventional cardiologist? I don't see how you're gonna be able to manage it. You'll be lucky to get through this fellowship at all. And that conversation has happened all across America in a whole variety of specialties for many decades. Or the program director might say, okay, we can help you get where you need to go, but for right now, let's put the timetable aside. I think you should consider asking for a formal leave of absence, focus on your health and the health of your baby and we will stay in touch and reassess on a regular interval when you wish to return. Okay, priority number one, take care of the patient, take care of the resident, take care of the fellow in front of you. Now, this fellowship program director though also has all those other fellows in the program. So how does the fellowship program director support all those other fellows in a way that is as fair as possible? And I'm now going to step into Nirvana. It's not a low challenge situation. And I know that it's not necessarily going to work this way, but in high challenge and low support, the fellowship program director could simply say, well, this is why there are so few women in cardiology. This is what needs to happen. I've made out a new schedule. You'll all be on every third night call for the rest of the year. That's not going to go over well, but it happens all the time. More healthy approach might be, I've gone to the department chair and I've asked for approval to hire an additional fellow outside the match. I will be also offering opportunities for other fellows and third year residents in medicine who might be interested in cardiology to take some of the on-call responsibilities. Now, again, we can talk more about whether Nirvana exists. And I know and actually sat up in the seats where that kind of a request would come through and often get denied. But that's, you know, let's just say that this would be a more ideal situation and one that we should all be fighting to make happen. Okay, so I promise that I was going to share some frameworks and I do wanna allow time for questions. So let me share those frameworks and then we'll get to some conversation. So one framework is well known to those of you in the audience who focus on ethics. And that is we should be using an ethical framework for training the next generation of physicians. If we were to do that, how would you assess how we're doing on these four domains of autonomy, respecting persons and their right to make choices, beneficence, obligation to contribute to a person's welfare, non-molificence, obligation not to inflict harm, and justice, the distribution of resources in a fair and equitable manner. And I just invite you to reflect on, you know, the three cases and the many cases that are well known to all of you and think about how well we might be doing or not as a profession. The other framework is the one that I introduced at the very beginning. So this framework, as I said, is meant to apply to individuals, our patients, to systems. And we cannot apply this to our patients and our systems if we don't also apply it to our healthcare professionals. And so how are we doing in those domains? And what will it take to change? So I wanna conclude by talking about what will it take to change? And invite all of us to look at the image from the Agnew Clinic from long ago and compare that with an image of our own internal medicine residency program from the mid 1990s. We have clearly diversified this profession and I've shown you some of the data about that. But I've also shown you the data that demonstrates we have not achieved equity and we continue to propagate inequity from our assessment systems to the policies that we enact both locally and nationally. So what is it going to take to achieve equity? One is to dismantle the training and career pathway expectations that are based on the traditional model. And that traditional model was invented more than a hundred years ago and we've made very little incremental change around that model. The second is to dismantle a culture of education that disproportionately mistreats women. And we've seen that data in our graduation questionnaires for many, many years. And yet we keep seeing the same kinds of data reported in the medical literature that I shared with you here today. We need to address and combat and correct this physician pay gap. And I know you have work underway here that you've been at work on now for many years. We need to recognize and reward the work that's not compensated. And I gave you examples of that. And then very specifically, we need to provide on-site affordable childcare and resources which promote healthy parenting. And I would have a lot more to say about that if time allowed. So I know most of those things take money. However, I believe there are strong and powerful quantitative arguments that could be made that then allow us to tee up choices about how we use our money. And I believe those arguments could be very persuasive by looking at the toll that the various biases and discriminatory practices take on women in medicine in particular. So what strategies are really needed to reach the tipping point where I'd like to believe we are where we find ourselves. I would like to have thought we were at a tipping point back in the 90s when we achieved equity, with diversity on this campus. And now you've seen, we've had at least a decade really of diversity in medical schools, but our pipeline doesn't have that. So there are three agents of change according to Malcolm Gladwell in his book, The Tipping Point. The law of the few. And that means taking the people who are the connectors, the managers and the producers to make real change. I believe you have all those people right here at the University of Chicago and you are in positions for a national platform to make real change. The stickiness factor, what can you do in the various tactics that you might take that will have the stickiness that will be durable over time and not just dependent upon who the department chair is, who the dean is, who is the person who has the decision-making authority, what are the stickiness policies that will allow this to really be a new world for the next generation of physicians. And then finally, the power of context. And that is to examine health and healthcare in America today, to examine those who are choosing to pursue careers in medicine and using that context as the engine to drive real change. Why do we wanna do that? So that together we can all flourish, our patients, our population, and importantly, the women who are choosing a career in medicine. I'd like to thank my colleagues at the Macy Foundation who I have the pleasure of working with every day and a particular shout out and thank you to Dana Levinson who joined me at the Macy Foundation a little more than a year ago, two years ago. And she's here in the audience today. So Dana, thank you. And I know that many of you will wanna say hello to her. So I'm gonna stop there, Julie and we'll be happy to take questions. Great. Dr. Levine, you wanna ask the first question? That's so great. Thank you so much. I have a question about that flagging number only about 18% of women achieve who are coming to department chairs or deans. And it seems to me that now again, there's more and more organizations that are luckily looking for a new position. So the more we're looking for women, yeah, women are still being held back and feeling that they're holding back themselves to go after those positions. What should the universities be doing to help promote their own women to encourage them to look for these positions or think about achieving the higher level women are. Okay, that is a great question. And I think it starts with who's in the pipeline and I think you are in a very good position here on this campus, but nationally, we also know the beginning of that pipeline in good shape. Search committees need to be composed of a very diverse group and in particular, but include women, not only as members of the committee, but when appropriate and often I hope as the chair of those search committees. Identifying the women's candidates as well as your pool of candidates, but in particular, setting up the interview day and the whole process in a way that is supportive of the person who you're aiming to hire. Once the decision is made to hire, that's when actually the real work begins. Some people think the real work begins by having a coach in place, and that's important. Coaching and having a support system in place, but very often institutions fail on the support system that's in place. And I would say I really have a transition team made up of more than one person and that transition team would not only welcome the new woman's leader to your institution, but would be composed of thought leaders, individuals who have their connections within the institution to have the back of the person who you're hiring as your leader. And then the institution as a whole needs to stand behind the leader, have a lot of forgiveness when things go off track and the ability to help that leader be successful. As a professional, I think we have done a horrible job in general, how we support our leaders. We toss them out when something goes wrong. We don't really set up a system to help them succeed. So I think we have to carry it through the full, to the full end of not just the appointment, but to the successful performance ultimately in that leadership role. Now, having said all of that, I think it is very important that the individual who we want to promote to apply for those kinds of positions be coached and guided about speaking a new language, speaking the language of quantitative argument. So not just making an argument based on the qualitative reasons why the strategy should be put in place, but quantitatively. Why is this a good business decision? What is the profit ratio? What is the margin on this decision making? What kind of investments are we going to do? Sometimes in order to speak that language, people will need a really in-depth background in business and financial analysis. But that doesn't mean you have to have an MBA. That means you need to be intentional about how you prepare for those kinds of roles. Likewise, I think the community, meaning all of us together, need to decide what do we value most and how are we going to hear the messages that come from the leader? And are we open-minded in giving people the benefit of the doubt? Or are we harsh and critical and ready to move on to the next leader as soon as some mistake is made? And I think that framework actually applies to all genders of leadership. So I kind of took your question from women leaders to leadership in general. Wonderful, there's a few questions here and so then I'll come back to you and they can't hear and let you speak. Oh, sorry, sorry, sorry. So this is an anonymous and I think this was a really great question based on the kind of scenarios that you gave is basically there's often in these scenarios that you gave tension between giving immediate feedback to the person because there's not anonymity if you give the feedback right away versus in the typical situation we would wait six months and then aggregate feedback and then say to the person that these things happened. So what the person's question is what are your thoughts about this practice and what's the best way to address and it's treatment in a timely manner? Okay, thank you for that question. It is a really important question. And the first thing I wanna say is please don't wait six months. I understand why you would so that you have aggregated data point but I would say number one feedback in the moment or shortly after whatever incident was is extremely important. Number two, most of us unless we trained in psychology and psychiatry may not have the skills to be able to do that feedback in a way that is comfortable and effective. And so know what you don't know. And when I didn't know how to have a conversation like that I would call someone who I knew knew it better. Elizabeth Keith right here in the audience is someone who I could call and say, hey Elizabeth, I have this situation. I'm thinking I'm going to say this and sometimes she say, Holly, that's exactly right but sometimes she say, well Holly you may wanna reframe it this way. So anyway, important to give the feedback immediately or as close to the situation as possible. Don't worry if you feel uncomfortable because we all do know how to get help for yourself to give difficult feedback and know who your resources are to draw and to get that help. And then if you find yourself lost there are two little tricks that I've used my whole career when I found myself in that kind of a situation of giving difficult feedback in the moment. The first one was question asking how do you think this went? What do you think happened with Mrs. Smith on the oncology service last week? Every time I asked that question I learned a whole lot of things I didn't know before that actually added texture and context that was extremely helpful. And the second little trick I used when the person in front of me just was not making sense and even if they pushed me to the point of clenching my own fists and teeth like why did you do that? And I wanted to say something that I might later regret I would say to myself, Holly someone loves this person. Might be their mother, might be their spouse but somebody loves this person. Control yourself, Holly, you know there's someone in the world who really loves this person who is driving you crazy right now. Now that is not based in psychology or psychiatry it's just a little trick that worked for me. So if it helps you I share it in that spirit. Elizabeth, did you wanna ask your question? Yes, so great question. So the first question is based on my experience in medicine where if I could choose only one place for an intervention where would it be? And the second part of the question is based on everything I've seen across the country is there one example that we could all learn from? So I'm gonna answer that question but I need to preface it by just saying I'm biased based on my experience but the one place I not only would but do every single day focus on with a laser beam is the clinical learning environment. Our training environments that our residents and students are working and learning in could be vastly improved compared to the historical programs that we have in place. So the clinical learning environment and what is the key or there are many keys to the clinical learning environment but among the most important keys are engaging our male colleagues as allies. Our male colleagues were my personal mentors. My male colleagues are the reason I stand before you today. My male colleagues are the direct reason that I had the chance to have a career in medicine. And that's not uniformly the case all across America but I know that we have men at the University of Chicago who are incredible allies. And the more that we can draw from them from their experience, their wisdom and their allyship the more we can make a change in our clinical learning environment. And I know you're all doing that actually every single day in the clinical learning environment but broadly that's where I'd focus. What have I seen by way of example that we could learn from? I'd love to come back and give you a talk on that because the Macy Foundation has just launched a catalyst awards. We've just identified seven institutions for our catalyst awards and the catalyst award winners who we chose the seven who we chose all to organize themselves spontaneously not at our direction but they all organize themselves spontaneously around a theme of creating environments of psychological safety without bias and discrimination in the clinical learning environment. So one of the projects at Duke University is to train their leaders and residents as civility champions. So anyway, I could go through all of them but that's probably another talk. I'm just gonna ask one more talk. There's a couple more but we can't answer so many but Dr. Lester retired pediatrician, pediatric faculty basically asking about gender concordance. Does the gender of the leader or the program director affect the with the gender of the trainee and how you manage the situation? Yes, thank you, Dr. Lester. It's nice to hear from you even in cyberspace and I just want to share with the whole audience that if you have not read Dr. Lucy Lester's book I commend it to you. It's a really comprehensive and beautifully written book about a long history of women in medicine. So thank you for the book and thank you for the question about gender concordance. Gender concordance is important for women and it's important for those who come from historically underrepresented groups in medicine but it's not the whole story meaning if you do not have gender concordance if you do not have racial concordance that doesn't mean you should back away from the opportunity to mentor guide and lead. So when you have it, it can be helpful it can also be harmful when you have it. And so I would focus quite particularly on the skills and investment of the guide and mentor irrespective of their gender. Well, let's just give one last thank you to Dr. Humphrey. Next. Next week we're going to be joined by Dr. Laney Ross who as you know was one of our pediatric faculty has moved to Buffalo, but will be joining us back in person back in P117, talking about gender equity and publishing and editorships and things like that. So excited to continue this amazing lecture series. So we will go ahead and close this part of it and then ask the ethics fellows to come down to the front to continue this more personal discussion with Dr. Humphrey. So see you next week. Give us our party here. Let's go. The challenge. Wait, where's the mouse for this? I just want to speak with you. I can type screen me. Good. Good. That was great. That was a wonderful... Thanks Dr. Humphrey. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.