 today and it popped up with something. Perfect. So I will go ahead and introduce Dr. Sapo. Welcome everyone to the McLean Center for Ethics and our lecture series Gender, Equity and Ethics. We're really excited for our winter series. As you know, it's Wednesdays at noon here in Chicago, sometimes virtual and sometimes in person. And this is going to be our last virtual one for a while. The next five are actually all in person, including Dr. Holly Humphrey from the Macy Foundation next week. And then a number of our colleagues here internally, although Dr. Lanie Ross coming from Buffalo, and then Dr. Karen Kim, one of our internal colleagues in the Provost's office. So but for now, let me just welcome and introduce Dr. Sapo. Dr. Sapo is a board certified HIV primary care physician and public health advocate and the founder of Just Equity for Health, which is a health care improvement company that uses advocacy, education and the care model design to ensure equitable care delivery across all sectors of medicine. Dr. Sapo has experience in clinical transformation and health care redesign at Mount Sinai Health System and Premier, where she respectively serves as an assistant professor and the strategic advisor. In addition to her commitment to population health and care model design, Dr. Sapo is dedicated to equity within health care. She is a founding member of several organizations dedicated to gender and racial equity and to civic engagement in medicine, including Equity Now at Mount Sinai, Civic Health Alliance and the Coalition to Advance Antiracism in Medicine. In addition to an invest to an investment in projects around equitable care model design and to a commitment of social justice work, Dr. Sapo also provides clinical care to patients in New York. Her work has been featured in various academic and popular media, including CNN and MSNBC. So welcome, Dr. Sapo. We're so excited to have you here and I'm here about your about your work today. Thank you so much for having me. It is a pleasure, Dr. Euler, Dr. Aurora, everyone who made this day happen. I wish that I could be there in person, although I heard it's one degree and so maybe I don't. I am calling to you guys, we're talking to you guys from Brooklyn, New York. And again, I'm just really happy to be here. I will go ahead and jump into our conversation so that if folks have time for questions, we have time for that at the end. I will I assume just like zoom etiquette stuff. If you have a pressing question, you want to speak up, you know, while I'm presenting, I won't be able to see you, but feel free to put a question in the chat, put your hand up, whatever is helpful. And I will make sure that we keep time at the end for us to continue this conversation. Okay, so I will go ahead and share my slides. And we just get that up. So I am very excited to be talking to you today about navigating workplace adversity. And I kind of framed this talk with a slightly different title, because I think that this really captures it, which is we are talking about this, how we overcome and become creating meaning and impact through and despite workplace adversity. And it is my pleasure to be here. These are my disclosures. It's a pleasure to be here with the background that I have. And I want to share that with you because it really does impact kind of how I see this problem, and how I think about the solutions to this. So I am a clinician, like many of you, I see patients in my HIV clinic every week. And through that lens of taking care of some of, you know, the most kind of historically marginalized individuals within our healthcare setting, I have seen the ways in which our health, our delivery, our care delivery system, often does not meet the needs of patients. And, you know, for a better or worse HIV patients in some ways have the most resources. And so if they are canary in the coal mine, we know that our patients just are not having their needs met. I'm also a systems designer and a work with health systems and with large healthcare improvement companies. I'm thinking about in both the local and national context about how are we creating the models of care that meet our patients needs and who are we leaving out? And then I myself am a patient with a chronic medical condition. And I think about this question from the user perspective, it's always interesting to me when I'm engaging the healthcare system and seeing specialists or an urgent care, the difference when people know that I'm a healthcare worker myself, when I say that I'm a clinician, versus when they see me as just a black woman, youngish appearing seeking healthcare. And so all of these perspectives as a clinician as a designer as a user come to mind as we have our conversation today. And the objectives of objectives for our conversation is we're going to review the contemporary challenges to long term career success for women and historically marginalized groups within healthcare and how it ultimately impacts patients care because that that is what we we are always focused on first. We're going to outline the practices, the resources and the tools for successfully overcoming workplace adversity. And I want to focus on some of these day to day interactions and give you some of the resources and tools for that. And I localize this talk certainly within the literature, but also within my experiences and the experiential learning that I've had the pleasure and displeasure of knowing firsthand and through the now over, probably 200 individuals that have reached out to get help as they've been going through different challenges. And so I bring this to you and share it with you so that you can be able to kind of think about and help to navigate these spaces better. So I want to start off with some examples and these are based on examples that I have either been proximate to or has shared within our network. Obviously, slightly modified to protect individuals identity. So this one is titled It was just a matter of time. Catherine is an attending physician who has had trouble with her chair over the last few years. She's challenged him on certain decisions he's made, but she's found discriminatory towards women like not allowing or not making women kind of first up to get some of the office space. And so women are the primary are the primary ones who are getting shared space. After a medical student takes a picture of one of Catherine's patients during surgery and posted on social media. Catherine is blamed for having violated the hospital's ethics code and immediately placed on me. Second example titled because she knows who we are, but rather she knows who we are. This is an example of Michelle, who's always confused for her fellow resident, another black woman internist by the head nurse on the wards, despite correcting this nurse multiple times and the program only having two black doctors altogether. This nurse insists that she cannot keep the two of them straight. Michelle finds that whenever the head nurse calls her by the wrong name, other nurses seem to snicker and we think it's funny. She's not sure if she's imagining this, but it does make her uncomfortable. And so I want you to keep these two examples in mind as we're having this conversation because these are the real lived experiences, one of overt retaliation, the other of what some may term microaggressions. I want you to think about how these may have impact on these individuals, lives, careers, day to day experiences and ultimately on their ability to care for patients. So let's talk about the problem. And I localized the problem first within the patient context. We know that we have to think about equity because we know that access, utilization and quality have historically been inequitable across different intersexual characteristics, whether it's race, gender, et cetera. And here I'm going to use the example of race and just give you some key kind of, you know, representative examples of what we've seen historically since we've been collecting these data. You look at insurance status, which represents access, non-Hispanic whites are about 6% in terms of those who are uninsured up to for Latin A population, 17.7%. If you look at chronic disease management like diabetes, you have rates of about 7.5%, among non-Hispanic whites, which is going up. And as high as 12, 18% and in some parts of where I work, up to 18%, rather it's up to 11% here, but up to 18% in some of the populations that I'm working with. If you look at mental health services, and so those who have access to mental health services, which can really make a difference in how you manage many of your other biomedical problems, almost half of non-Hispanic whites are able to access this and only 30% of other populations can get that. Same thing carries, maternal mortality, infant deaths, HIV treatment rates, et cetera, et cetera. So we have known this historically and what is interesting is when you bring into this picture emerging pathogens. So diseases that humans have never seen like SARS-CoV-2 or diseases that we haven't seen in our environments like Mpox, you get the same realities repeated over. So Mpox, we saw that Black Americans make up a little over 10% of the population, but they were almost 30% of those who were infected. And yet when it came time to get vaccines, they were underrepresented for vaccinations. And so it is kind of first up for case counts, but last, when it comes to getting life-saving treatments. For COVID-19 rates, this was a really, really interesting map that came out of the Department of Health and Mental Health out of New York City, which just did by zip code where the most cases of COVID were in the darker purple or higher cases. And I just mapped on top of this life expectancy. And so if you look at the 84 years, that's midtown Manhattan, where even before COVID, life expectancy was about 84, whereas in Brownsville, which is close to where I live, it's about 73. And so this 11-year difference we already knew. When you brought in this brand new disease, what we found were that in those richer, wider areas, less cases of COVID in other areas, much higher cases of COVID and studies have shown that this tracks to rent burdened households. So those with lots of individuals within the same household, those tracked to the number of service workers that you might have within the spaces. And so there are very, very clear reasons for these trends that we see. And overall, this has led us to the reality that life expectancy has decreased significantly in the last few years. From 2019 to 2020, all Americans lost about a year and a half. But Black Americans lost three years compared to the year and a half that the White Americans lost. The groups that are even more impacted, you look over here, it's American Indians and Alaska Natives since 2019 have lost 6.6 years in terms of life expectancy. And so we have seen this historically in the slide that I just showed you. We know it for emerging pathogens that there are drivers that are causing us to really struggle to understand what's happening with health outcomes according to different intersectional characteristics. And one of the explanations for this, there are many, but one of the explanations is looking at the structural causes, the social determinants of health. And the reason why the equity folk, and these are, I'm assuming that everyone kind of, you know, has talked about, knows this, language of this, but they're all the non-medical factors that influence health outcomes. So it's economics, it's built neighborhood, it's social community context, like police brutality and the criminal justice system, it's healthcare access, it's education, all of it has an impact on how people experience different disease states. The focus on equity within healthcare is happening now because we're talking about things like population health, where health systems like your health system gets paid according to these value-based contracts. And so because of that, they have to think about, well, what's happening with our high utilizers and why are the high utilizers? What's happening with the whole population, folks that never come in and why aren't they coming in? How do we access them? And then I want to that there is a growing and increased societal consciousness since COVID-19, and some might say the brief racial reckoning of 2020 that is leading us to really have these conversations about equity within the healthcare space. And so to define it for a quick moment, health equity is achieved when every person has the opportunity to attain his or her full health potential. And no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances. And here, what's important is that this is different than disparities, which is the language that we use in the 2000s and 2010s that just describe the difference. The equity focus is really trying to make us think about what are the societal causes of these differences. And so that brings us to what I think is very important to discuss, which is the things that are driving inequities that are patient outcomes are also impacting the way that our healthcare workforce are experiencing their day to day abilities and their day to day abilities to carry out their tasks within the healthcare setting. So this brings us to talk about discrimination and adversity, which are words that I'm going to be using through this talk. And I want to make sure folks have an understanding of what I mean by those. When we talk about discrimination, this is prejudicial treatment of a person based on their membership into a certain group, race, gender, etc., some of the characteristics that I've mentioned. And there's a legal definition here because there's legal protections against discriminatory behavior within certain settings. And we saw this in the Civil Rights Act of 64 and the Educational Amendments Act of 72. That's a little different than what I'm talking about in certain cases, which is adversity, which is the on the ground challenges that may create a toxic environment that impacts a person's ability to successfully execute their job duties. And this matters in healthcare because in healthcare, we're taking care of people's lives, right? We're not, you know, doing care or serving wine, all incredibly important functions, but we're taking care of people's lives. And so it matters to us that people have the best workplace environments to be able to execute, especially when we see that our health outcomes are very differential by the different groups that you're in. So we start talking about discrimination and intersectional identities. I want to really kind of frame it in a way where you may hear me say women, you may hear me talk about black Americans as a representative group. But there are many characteristics that have to be considered. And these characteristics often intertwine in our kind of rolled into each other around the ways in which the identity that folks have intersect with racism, bigotry, sexism, disability status, transphobia, xenophobia, and we find ourselves within a cultural time where there are more policies and bills that are legislating against people's characters and, you know, characteristics and people are calling out what have happened historically around racist treatments within these settings. I just want to as we start this conversation kind of remind us of why this stuff kind of matters. When you look at black Americans making up 13% of the population, but only 5% of those who are physicians, we know that something is unequal and is wrong within this setting. So going into the numbers, going into so what's happening. I want to talk to you guys about where we find ourselves in terms of discrimination. So 2018, the National Academies of Sciences and Engineering said that for individual women faculty that they queried about 20 to 50% reported gender-based harassment at some point in their careers. These numbers go up much higher for physicians of color. 70% of black healthcare workers report experiencing some form of discrimination. And what's interesting here is that this is the highest for all racial groups that that we study. And the types of discrimination that they're facing are both overt and subtle. So people use the language of conscious and unconscious biases. And here, what is particularly interesting is that black individuals tend to experience the refusal of care in terms of working with racially discordant patients where people will say, well, I don't want to be taking care of by that doctor. And that matters because obviously there's something happening there that has an impact on patient outcomes. It also has an impact in terms of the kind of moral injury that these individuals are experiencing. So the problem is pervasive. The problem is bad. And the problem isn't just happening at this kind of larger, high level. The problem is also happening at an institutional level. And I say this because sometimes people hear these numbers and they think, well, it's not that bad at my institution. In 2019, I did a faculty survey and found that in the last 12 months, 25% of women faculty reported sexual harassment, that sexual harassment, which has its own set definition. And so this problem is pervasive. And it matters what context you're in. Discrimination is worse in certain specialties. A study of 334 women learners and general attending surgeons found that 87% reported experiencing discrimination within medical school, 88% said they experienced it in residency, 91% in practice. And so it is pervasive throughout the experience. And it is why only 15% of women occupy the general surgery world. Right. It is it has such an impact in the way that people are experiencing everything from their training to their young attending days that it is dragging people out of the ability to perform and work in some of these fields. Trainings are very, very vulnerable because of the nature of the learner-teacher relationship and because trainees tend to be younger. And when they experience acts of adversity or discrimination, they don't have the recourse and the tools to be able to really seek justice or to be able to have their issues addressed. It's also interesting to just know that when we're talking about this, the perpetrators of these tends to be in a supervisory role. So it tends to be that, again, that hierarchical relationship, but it can also be administrators. In the example that I gave, it was nursing colleagues or allied health professionals. And it can be patients and families. One thing that is incredibly important is as we start talking about this is to think about where the attention tends to go. And so in general, we tend to focus on overt acts of discrimination. So things like the sexual assault or things like someone being called the N-word. And those most people can identify as discriminatory. But it is often, and I don't tend to use this language because I don't think there's anything micro about microaggressions, but it is often things like microaggressions though, that lead to the day-to-day toxicity and the weathering that many people experience. So it's things like, can I touch your hair? Where are you really from? You speak such good English that the things that people kind of talk about. And I want to just give it to you from the perspective of the healthcare clinical setting of what this may sound like. And so this is what many Black American physicians experience, right? Greater scrutiny of your treatment plans. Being held to higher standards when mistakes are made. Having their competence questioned. Needing to justify your credentials. Lack of use of your titles when everyone else gets titled. Being mistaken for maintenance housekeeping or food service workers within the workplace. Nothing wrong with any of these service workers. They are the reason the hospital works. But rather, it's the day-to-day constant devaluing of what you're bringing to the team and questioning of your credentials that has an impact. And so when we're talking about discrimination, we're talking about the kind of range from what is historically kind of termed macroaggressions to the more overt forms of discrimination that people may experience. And we talk about this because it has a tremendous impact. And the impact really ranges, I think, across a couple of different avenues. So there's the impact. And I start here first because like you guys, I'm a clinician and I'm thinking about what this is doing to patients. There's the impact on patient experience and health outcomes. So gender and racial concordance with patients has been found to result in higher patient satisfactions. Patients love seeing a doctor that looks like them or they feel like they can talk to and identify with. A systematic review of over 40 articles found that physician-patient racial concordance, especially for Black patients, resulted in higher patient satisfaction and visit plan comprehension. And I just want to focus on the visit plan comprehension because like many of you, if you've taken care of patients with chronic illnesses, visit plan comprehension is everything. It is the way you're going to get those blood pressures checked, the way you're going to get the insulin numbers you need. It's really, really vital. And so if there's something in there that is happening through patient-physician racial concordance, for instance, it's worth examining and thinking about how this can impact patient outcomes. There are mixed results when it comes to quality, except Greenwood et al. showed in a study that they did looking at 1.8 million births in Florida from 92 to 2015 that Black patients with Black physicians, the infant mortality was lower than White physicians with Black patients. And this was something that is fascinating and interesting because the maternal mortality, infant mortality rates in this country are atrocious and there's a lot of effort kind of going into understanding what's driving it, but more importantly, how do we start to offer solutions? And so it matters if we're losing folks from the workforce. It matters on patient outcomes. It certainly matters for patient engagement and comprehension and patient satisfaction. What's the impact on burnout? And so one study out of the AMA where they surveyed 6,100 physicians found that those who reported higher rates of the treatment of discrimination also had a 28 to 120% increase of burnout. And burnout in general is worsening when it comes to COVID-19 and worst place inequities. Like we are seeing it at the rates that we've never really seen it before. Metscape did a survey of 1,500 physicians and they found that burnout was highest among women, almost 10 percentage points higher than men and among generation acts then compared to boomers and millennials. And I find this interesting. All the generational stuff is always fascinating to me. But the thought here is that it may be that with Generation X it might be driven by a degree of expectation setting where younger physicians are like, no, no, no, we're not going to deal with that or do that. Whereas Generation X might be this kind of class of physicians that has certain expectations and is in a cycle with leadership and administration that that that is leading to the types of work like imbalance that's driving burnout still being examined but it's a very interesting space. The consequences though regardless of what's causing it and who it's happening to or dire physician burnout impact staffing retention impacts patient outcomes and impact substance use and an impact suicide. And we already know the physicians have the highest rates of suicide among other professionals and this is the number that's actually pretty scary that they're 2.3 times more likely to successfully complete suicide than the general public obviously because of their medical knowledge. And a lot of this is driven by higher rates of depression anywhere from 19 to 28 percent versus 7 percent among the general population. So burnout really matters. It matters for us as individuals. You know, put patients aside for a second. You don't go into medicine to be denigrated and kind of not have, you know, your best life. And so it matters that we're seeing these numbers and it matters that it's getting worse and it matters that mistreatment and discrimination has a role to play in in driving forward burnout. What does this look like in terms of retention on the workforce? So gender based discrimination definitely has an impact on what we're seeing in terms of the numbers of those who are exiting the physician workforce and really the healthcare worker workforce. It's worth us remembering for a moment that even though women make about 40 percent of practicing clinicians, there are about 66 percent of entry level healthcare workers and 90 percent of the of the nursing workforce. So when COVID-19 was happening and we're thinking about, you know, the impact on the healthcare workforce, it was women who were really seeing the the exodus. We lost in April 2021 and alone 1.5 million healthcare jobs. And the reasons for this are multifactorial, but it's certainly in part because of the reality that pandemic, you know, driven increase in familial duties like caretaking and homeschooling did fall more on women and did impact their ability to remain engaged within within the the healthcare setting and within professional settings period. And then a national survey from definitive health found that over 230,000 healthcare workers left the field between 2020 to 2021. This is between like physicians, assistants, PAs and PAs. 86,000 to 86,000 of those were physicians leaving various specialties. But the specialties and you look up top at that table the specialties they left the most were actually between internal medicine and family medicine, which tend to be women heavy specialties. And so this is where, you know, 40 percent of internal internists are women and 50 percent of family medicine doctors are women. And so again, if we're seeing the numbers that we're seeing in terms of people who are leaving, it is concerning that that we're getting this kind of reality of like the great recession impacting healthcare in this way. I want to read to you these words from Dr. Seed who just describes I think the end of years of the struggle within healthcare because many of us probably can identify to put the stats aside for a moment and just think about the lived experience of what people are going through. And he says there are wonderful things about being a doctor. Immense and unique privileges but understand doctors aren't just taught. Doctors are forged, melted down and reformed, made shapeless than given structure, destroyed than pieced together to slowly be broken again. So when people leave medicine and record numbers, understand it isn't always just a choice in the moment. It's a choice that can be years in the making. There's so much they take so much you give we all leave medicine eventually some retire and some set themselves free. I don't want any of y'all to set yourselves free. We're going to fix this problem so we can all stay. But these words really hit heavy. And then we think about the impact of equity work. And so there's a higher likelihood of women, especially women of color spending significant amount of their time doing institutional work. And the impact of this work ranges from things just as taking you away from promotion pro activities like more research teaching to real challenges around your physical and mental well-being. And there's the example of what happened to Dr. Michelle Morris and Dr. Bram Whisperie when Nazis little Nazis marched on the Brickham's campus because these two doctors and their colleagues implemented the healing arc framework, which is a reparative justice care model framework that allowed black cardiac patients to actually be prioritized on the heart failure service. And what it historically happened, which is that they were always the lowest, the last didn't get the services that the literal life saving services that were needed. And these individuals marched on the campus because they felt like by not having the kind of unspoken prioritizing of white lives, these efforts to kind of bring in other racial groups were devaluing white lives. And so the institution had to deal with this. And these doctors had to get security detail to protect themselves. And so there is there are consequences to doing this work and to doing this work well. And even before that, there's a moral injury as DEI and health equity work in general is slowly facing disinvestments, quiet disinvestments, but disinvestments, nonetheless, in the form of layoffs, removal from strategic plans and postpone implementation of what was promised in 2020 and 2021. So these impacts are tremendous. We're talking about impacts on patients, impacts on the health care workforce, impacts on worsening burnout and impacts on the ability to actually do this work when we situate discrimination and the experience of women in historical marginalized communities in the kind of day-to-day experiences that they're having. And this kind of brings us to this understanding that we have a leaky pipeline and we have stalled progress. If you look at women physicians in health care, the end of medical school, 50% have made it, well, 50% make it into medical school, 40% of individuals complete residency and yet only 30% of these individuals are active physicians a few years out completing residency and so at every step of the way, you're losing people. You're not retaining people. And if you think about the investment that you make into training clinicians and you think about what I mentioned earlier about clinician-patient concordance, these numbers are concerning. I offer you here an absolute count at the bottom of black men medical school matriculas. In 1978, when these numbers started being collected by the AAMC, there were 543 black men going to med school. 2014, that number was 515. Those numbers have stalled. There is no increase. There is no, and the percentages are even more kind of concerning. There's no increase in these numbers that has happened over these last 40 plus years. And so what are the causes of this? And we think about some of the representative causes because that's how we're gonna think through solutions. And so I'm a systems person. So I think about it in terms of individual, systemic and structural. And under individual, we're talking about some interpersonal causes. Under systemic, we're talking about health systems and what they can do. In structural, we're talking about policies and culture. So taking the individual causes first. So it's things like less professional support like mentorship and sponsorship, which is really vital to being able to make career advances. It's things like interpersonal challenges with your chair leadership, we're just not vibing. Things like the toll that macro and microaggressions or otherwise known as interactional biases may have on individuals that may make individuals feel smaller and less able to participate in these social networks that can sometimes lead to success. On a systemic level, we're talking about things like lower salaries and the lack of pay equity. This particularly affects women, women of color. Less opportunities for promotion. So you'll see it where someone comes in, a man comes in, maybe and is promoted within a year. A woman of the same status didn't even know she should ask. And I've seen this before. It didn't even know she should ask for a promotion and she's been there two or three years. Lack of enforced institutional consequences when discrimination does occur. And this is really important because people learn, why go and report what's happening to me if nothing will be done and if I'm only gonna challenge my own career. There's an expectation to perform token work that may or may not be allied with one's true interests. But if your chair asks you to sit on a committee, you feel like maybe you should say yes and that's time away from other things that may be important for your career. Structurally, there's a reality of work-life imbalance, right? And this is what drives some of the numbers that we see out of the surgical specialties and women being really precluded from that. Unforgiving parental leave and caretaker policies. Again, if a family unit has to decide who's gonna take care of grandma, who's sick, it falls on certain individuals in more ways. Lack of role models and funding to allow easy entry into the field. And I say medicine is a rich man's profession. I just had a conversation with someone earlier this week who is a young woman who wants to become a clinician and set up her pediatrics practice in Brooklyn and take care of her people. And she is now on her second try of trying to get into med school. And she said to me, people who live with my family, they're not doctors and I have no one that I can ask simple questions of. And so she saw me give a talk and like reached out to get basic information. That's who we want in this profession and yet they can't get in, right? And the cost of legal fees and forced arbitration that prevent many from seeking justice when something does happen. So these are not all the reasons. These are some reasons. And I think some of these will resonate with some of us. And thinking about it in this level allows us to think about where can we locate some of the responses to this on the individual level, on the systemic level, on the structural level. And so let's talk about why we're talking about this problem now. And I think we're talking about it now because there is an urgency of now. Women and people of color are being driven from healthcare because of the combination of burnout and unsupported or outright hostile work environments. And when they are facing adversity, they often don't have the tools, financial resources or networks really to navigate it successfully. And so we have to equip ourselves with these tools, networks and resources. But the first step to all of this is to recognize the problem and to do so early. And yet as we talk about this learning to know the importance of recognition, I wanna just name some of the things that do prevent the ability to recognize the problem. Part of it is culture, the culture of medicine. You're not sure what a problem is. You're like, is this toxic or is this just my medical training? Some of it is our internal narratives that we tell ourselves. And then some of it is the bottom of the iceberg, which is the types of situations that you're in are so nebulous that it's hard for you to know what it is that you're experiencing. So medicine is unique culture. Medicine is based on an apprenticeship model where much of medical training is founded on differential hierarchies, tough feedback, high stakes, and you're often in a position where you're isolated. You've moved from that school, you've moved for residency, you've moved for your first attending job. And so, and then I wanna just note the high stakes. You've been doing this for years and you have a ton of debt. So you're not gonna do anything to cause any issues even if you're in a toxic environment because the stakes are just entirely too high. This is made worse. City and JAMA found that it's made worse in places that are male dominated, that are permissive compliance policies and procedures. In other words, you have your policies on the books but you don't actually follow them when someone, especially someone in power compromises that. And places where there's a lack of commitment from leadership. And so the things that I have heard, and I've heard this many times, I'm putting this here for you guys. I couldn't tell if something was really wrong. I thought it was just me. I hear this often. And it is difficult to tell how much toxicity is too toxic in a way that kind of makes me think a little bit of the military that you're in this space. It's a very unique space. And in the isolation and in the hierarchy, you just don't know if what you're experiencing is a problem. Next is those internal narratives. And again, summary of kind of my experiential immersion in this, I'll share with you some of the things that people say to themselves or repeat to themselves that really holds them back from acknowledging and recognizing what's happening, which is, we're the lucky ones. I'm the only one in my community that made it, right? Recognizing something is wrong means you have to do something about it. Admitting we're suffering from a hostile work environment reflects poorly on us. Our communities are depending on us, so we cannot fail. You face a lot of adversity to get to this point. Others, our families or our elders have had to deal with much worse. And I hear this a lot for those who are not from this country, like my family's from West Africa. And we're used to soldiering through hard things. So these internal narratives create this sense of self-blame, really victim-blaming, that whatever is happening must be located with you and that you have this kind of internal strength and fortitude to be able to just navigate and drive your way through it. And if you're looking at this, I'm sure some of this is familiar to many of you. And it's interesting, because some of this is probably helpful. It's probably part of the reason why we're able to make it through our MCATs, our boards, those long nights of training. And yet at some point, this can be very, very problematic if the environment that you're in does require you to recognize and act on abuse that you should not be facing. And then the recognizing is also difficult because some of the forms of abuse are not overt, like sexual harassment or retaliation, but are actually more insidious. And it's worth thinking about gaslighting. So gaslighting is this manipulation by psychological means of your opponents to the point where they question their reality and sometimes even their sanity. And so it's things like denying that you've said something and making them think that, no, you didn't say that, giving someone a work directive and then saying, why did you do that? I never said that you should do that. It's just things that make people really question the very foundation that they're standing on. And at least in action, emotional and mental distress, so that someone who has been gaslit, it is very, very, very damaging in the workplace environment. So part of the reason why this matters is that when these things are happening, you wanna be able to feel like your institution will back you up. And the very folks who are probably more likely to experience some of these subtle and get hostile work environments in a survey of 2,800 black and Hispanic women physicians, most of them found that they were about, they believed that their DEI supported the institution that they was rated at about half a point lower than white male counterparts. And the reason why this matters is that, again, as you saw in the internal narratives, if you don't believe that any support is coming to you, what is the point of recognizing the problem? What is the point of kind of seeing what is happening if you're not gonna be able to be supported and responding and dealing with it? And yet the consequences of delayed action are pretty tremendous. By the time it's clear that something is wrong and you need help, you're emotionally depleted, you've lost some options for support, you may have compromised your networks that could help, there might be some mental and emotional inability to seek accountability, and you're financially unprepared for what might be coming, whether you can get fired or retaliated against. And the kind of thing I wanna emphasize here is that it does matter if you move early in that example I gave of the resident who was being targeted by the head nurse. You don't know if the head nurse is going around spreading rumors about you as a clinician that you're rude and me and angry, right? Those are the tropes that are often heard. So by the time you go and seek help from your leadership, they may have already heard that you're the problem. So it makes it harder for you to be able to then kind of get the support and the support or framing that you need to have at that point. So thinking about all of this, it kind of brings us to a place of how do you recognize some of these things? And there are a workshop and there's a workshop series that I do to really dig in deeper with this, but I wanna offer you guys some common themes. And so you start to know that there's something that's wrong with denial of promotions or job opportunities or disinvitations from meetings is often something that you see, a cooling of previously warm relationships. And so your colleague would text you and talk with you about things. And now suddenly, ever since you spoke up about being concerned about a policy or something that has cooled and you have to question, what else is gonna come? Hypercritical of job performance, differential treatment compared to colleagues. And then this is interesting, obscure complaints about your work that's often accredited to colleagues or patients. So you'll get the feedback while a patient said X, Y, Z, and yet you can't get any evidence of what patient took was or how it happened, when it happened. It's all very nebulous. And then outright retaliation. And again, I emphasize this, your ability to recognize that something is wrong can make the difference between being able to successfully navigate a challenge to your career. And so early action really, really is key. And so I wanna talk about that action, right? I never give a talk where I just talk about the problem and then leave you in despair. I always try to talk about, so what can we do? And so there are many, many things that we can do. And I started from this place of understanding that we are the ones that we've been waiting for. Institutional support, unfortunately, for many individuals who experience workplace discrimination is often lacking institutions, especially things like HR bodies are there for the institution. Third-party reporting bodies may have conflict of interest like the ACGME or the LCME. The case out of Tulane recently were one of the individuals who was perpetrating a really unhealthy environment for a black woman program director was actually also a member of the ACGME. And so it was difficult for them to know how to move and how to really navigate for help. And then national advocacy bodies like Times Up Healthcare have failed and have been found to be actually untrustworthy, right? And how do we repair kind of that loss of public trust? So recognizing an interesting workplace discrimination is up to the individual and it's up to us in our collective circles. I wanna encourage your framework of thinking about this from the individual level, the systemic level and the structural level. So taking a look at this, there are some solutions and kind of that can target each of these at the various levels. So from the individual levels, we can use tools and playbooks and I'll talk to you guys a little bit about that and I'll use some of my own experiences. We can think about how we support our people from the health systems level. And then for the structural level, we could think about what it is that we're doing to invest in advocacy to help us to target some of these policies. So on the individual level and again, there are further trainings that you can do in this, but the kind of highlights are you as an individual can do certain steps, these five steps, five steps to freedom where it's important that you know your rights so you know how you're able to advocate. It's important that you've documented what's happening without the evidence and kind of the receipts, nothing can move forward. It's important to know how to frame your relationship with HR and those initial conversations. And then there's actual things that you can do especially within this kind of larger environment to in a protected way advocate and move as a collective to be able to bring attention to whatever you're dealing with and to help you with whatever you're dealing with. And then it's important to create a plan for blowback, a safety plan that'll help to actually protect you and get you to a new space if you need to get to a new space. And so this is actually a two hour workshop that comes from this that I have led and I teach and I'm happy if there are questions that kind of go into more detail with each of these but this is one way that we as individuals can be more armed to be able to do this work. Learn from others. And so I am a member of Equity Now at Mount Sinai and we are in a federal case against Sinai for gender, age and race discrimination and in our time together, eight of us and the hundreds of supporters that we have probably thousands of supporters that we have if I count the national numbers have learned a tremendous amount. And there's mistakes that we made and there are successes that I think we've had that we've learned from but some of the mistakes are some of the things that I mentioned to you like we waited too long and we didn't plan ahead. We trusted HR and gave them everything and they used it to kind of undermine us. And our success here is that we banded together and we got good legal representation. We were able to get our documents together in a way that helped us move our case forward and we made noise in a way that since our cases come out has led to tremendous change within Mount Sinai as an institution. Now they will never thank us but it feels good to me knowing that people there are a little bit more protected and we're still in our case but it's created a platform that has allowed others to be able to share and advocate and we've seen it kind of help others in real time. And so these are some individual ways you can think about how you can support yourself. And then from the health system perspective or from the systems perspective how do we support our people? So I think about this from the institutional and the interpersonal. Institutional actions so having actually accountable reporting bodies that actually do some real work I think are incredibly important having clear anti-racist plans especially for residents. So the kind of thing that I've said here about being called the N-word I cannot explain to you the number of times that I've heard this or being refused to be a provider to patients and a lot of places don't have a policy for this. And so what happens is the individuals who are experiencing this feel like it's their problem, their issue they have no protections. And so institutionally how do we protect individuals especially our trainees? Protections for those who are doing DEI work and so providing security detail paying for digital protection like delete me and other things that prevent doxing institutions have to step up to the plate to make sure that those who are doing this work are protected. And then writing letters of support when you get public backlash like at the Brigham or in South Carolina that was doing a lot of really good work with transgender health to be able to or was it, I'm sorry, it was Boston to be able to say we support this work and it's important in the interpersonal kind of collective action it's creating our own networks because a lot of the work that we need to do to really change these systems require an inside and outside perspective. And so yes, inside there's some institutional things but what if you're outside some of these institutions there's organizing that can happen and so groups like Black Dock Village Physicians Just Equity are groups that are doing a really good job of being a landing space that helps clinicians who are facing discrimination adversity being driven out of healthcare. It's kind of like a group support model to really help them to land somewhere better and to help them to make sure that they're okay. And then the work that I do the workshop series is called Thriving in the Last Smile again, it's this idea of what's the collective wrap around that we can do to make sure people learn what they need to learn and where they need to end. And then finally, I would say that another solution that really targets the structural causes is investing in advocacy. And so if you think about this kind of environment that we're in, a lot of what is facing our patients and certainly leads to the moral injury that drives people out of healthcare are these policies around abortion rights, transgender laws or anti transgender laws climate change policy, police brutality policies all things that impact our patients down the line. And so the advocacy that it takes to be able to target this is important. Furthermore, a lot of the policies around accountability, pay equity, caretaker support requires us to engage with our lawmakers. And so I always argue that if we care about these issues we should be thinking about what it is that allows us to have more of a voice. Whether it's a Vodi or the organization that I have helped to co-found the Dr. Avora is an advisor on Civic Health Alliance. We're really thinking about what civic engagement looks like in the healthcare setting in order to be able to move forward on some of the policies that protect all of us. And here I really want people who are like, well, this lady's been talking about women and minorities I'm neither of those, I'm good. I want you to think about the privilege that you may carry because in the world of advocacy this is the space that you're able to bring your collective voice, your collective power to bring about change. And again, that change and that improvement impacts all of us. So going back to these early lessons and then I'll wrap and I'd love to take questions. This person who was the example of Katherine who was targeted and it was just a matter of time before they found a way to get rid of her what she needed to do here, hindsight is 2020, what she could have done here that might have helped her is to actually get legal support early. And the reason is because it was clear that she was on a pathway that could have led to something like this. And by the time this happened she was recommended and placed on leave. And then she had to go and find legal support. It was the timing was too late for her to be able to come back and say, actually, my lawyer and I would like to have a conversation about what XYZ has happened. Here it also mattered that she could document because I said it very loosely here. She's had certain run-ins with the chair, right? And it's not clear what those run-ins are. What did she say? What did he say? Is it clear that she was challenging him? Right now, now that she's been placed on leave and it's for a reason that obviously violates patient confidentiality, it's harder for her to go back and say, well, this happened this day. And I think that that's why they're against me, right? And so that documenting as things were happening is incredibly important to allow some of that protection when an action hasn't taken against you and you need to be able to come and say, here's what has happened. For Michelle who is in this environment where she's being targeted and kind of microaggressed with this, oh, I thought you were this other resident. It's important for her to just engage program leadership that she needs to be on record saying, hey, I don't know what's happening here. I don't know if it's an issue, but I feel as though I am being targeted by this individual and I just want you to be aware of it. And what this allows it to do is that if it ever escalates, it isn't her then coming to a program leadership for the first time, it is a pattern that she's able to kind of speak to and say, remember in November when I told you about this person that's kind of targeted me, this other thing has happened and I'm just wondering how I should move. And a lot of times, especially if it's not within the healthcare system, it's not within the kind of same field. It has to be a kind of a nursing leader to resident leader conversation that's gonna be able to really resolve this issue. So I wanted to come back to these two examples because there are things based on what we described that can be done to really be able to target and understand this. And so I'm gonna wrap, feel free to throw in questions that you may have or to think of questions that I'd be happy to take them but I wanna end us with a promise. As Dr. Kamara Jones has said, action is power and collective action is radical power. Some takeaways and considerations to think about just kind of in summary is health inequities persist and workplace discrimination and diversity unfortunately threatened to drive out important sectors of the healthcare workforce. We're seeing this happening in real time. Drivers of workplace discrimination can occur on the individual, institutional and structural levels. So the solutions must then be targeted to these leavers and they have to come from us as individuals in collective groups. Cause as I've suggested, no one is coming to save us, right? Ultimately, keeping those who are historically marginalized within the healthcare field benefits all of us and it especially benefits our patients. So I'm gonna localize the urgency of now is because of patient care. So I ask all of you, what more can we all do today? What are we already doing and what more can we all do to really target and address this problem? I'm gonna share with you some selected references that I've used and I wanna thank you all. And again, I wish I could be with you in person but you can feel free to reach me at this email where you can find out more information about just equity for health with this QR code and I will come off of these slides and I'm open for questions. Thank you so much, Dr. Sapo, that was amazing and the practical kind of recommendation that the end were wonderful. I just wanted to reflect a little bit on those and then we have one question in the chat and the question and answer. If anyone else wants to type a question and the question and answer are happy to read those out loud and answer them live. So I am the chair of the Department of Women's Committee and I often have people coming to me talking about microaggressions and or gaslighting and I think this and I'm so glad that you've mentioned them and really had some tools about identifying them first of all, because that was very helpful but I wonder and I think what I struggle with is when the gaslighting microaggressions do not reach the level of like HR, but they're like consistent and persistent and what to do with it's not a Title IX. So and I think that is a big challenge for women and women of color is like, what to do when like the gaslighting is happening? I love the documentation because I think that probably doesn't happen. I'm just wondering documentation and then what would be your recommendation? That is an excellent question. I love that you've started on that. It is often really important. I think sometimes we forget to kind of acknowledge what happens when you don't get to acknowledge that something is happening to you. So I really appreciate that question because what's missing a lot of times and that's going on is our ability to say this thing is happening and it's actually really impacting me. I'm not going to sue, I'm not going to quit. But I just need to acknowledge that this is happening. So what I tell people in that case is it's incredibly important, especially if it's gaslighting it's incredibly important that you document it because gaslighting done properly, which often it is makes you question your own like sanity and your own ability to work effectively. So the documenting actually allows you to look back and say, oh, you know what? I wasn't wrong. Last week they told me to paint the wall blue and I painted it blue and not this week they said I should paint it red. This notebook says I should paint it blue. And I, you know, so that is a way that you're able to kind of just reaffirm your grounding. The other thing that I suggest when that happens is for you to find someone that you trust and that's incredibly important because in these environments you don't know who you can trust and just start sharing with them. That is key because sometimes when, especially for certain individuals that are in supervisory role when it's happening for one individual it may actually be happening for others. And the utility, and I mean, I'm going to speak for you know, you Dr. Euler and for Dr. Aurora like the utility there is that a lot of educators do want to know who problems are. They want to know like, is this person driving is this person just adding to resident misery, you know or med student misery? And so there's a way that that if you understand that it's a couple of others that maybe the action isn't that you're going to HR maybe the action is that you're able to gently share this person's on a good educator and over time that could serve for protections for others. But I agree with you, that's a very, very hard situation. If you do nothing else though, please document it because it will help you protect your emotional and mental energy to know what it is that you're in. Wonderful, thank you. That's really great advice. And then I, there's one question in the chat also about microaggressions and say basically this is tangential but they prefer the word microhurt, microaggression. It's more of an I statement than like a you statement. And so just wondering what your thoughts are about that micro hurts versus microaggression. I don't like, I just don't like the micro part of it because I feel like it's supposed, you know like if someone gives you like a micro bagel you're supposed to like be like, yeah like there's like, there's something about it that's supposed to be like the delivery of the thing was micro and so your response has to be micro. When, what the issue is here is that if you have, you know a thousand paper cuts, at some point you have an open wound. So it's the additive effect of those microaggressions that really has an impact on individuals. And so I think what happens when people hear microaggressions is they think well you should get over it it's not a big deal. But if this is literally, you know like your seventh time opening your mouth that day and someone's saying, where are you really from? It has an impact of you feeling like do I not belong here, do I? So that's more of my issue with it. And I think that, you know that question comes from an interesting place of thinking about how you localize who the actor is whether it's aggression or hurt. I think that that makes a lot of sense and that's totally fine. My biggest question is like what makes us think that these things are micro for those who are receiving it and receiving it in a way that is cumulative. Yeah, that's wonderful. And then another, there's just another compliment I think in the chart but maybe something to reflect on that this was very valuable for creating safe and empowered strategies given the current kind of situation in healthcare. How did you come up with the strategies I guess would be? They're the most tangible that I've heard for these like kind of nebulous concepts. And I'm wondering like how did these strategies evolve? Yeah, that's a great question. For me, it's all lived experience. So literally I created the Thriving the Last Mouse series and created a lot of this work thinking if I could talk to Stella of seven years ago what would I tell her? Like what would I sit this young, happy, trusting, bright woman down and say to her? And I would say these things. And it is important for me as I frame these things to not have people leave with a sense of cynicism like everyone's bad and we're all screwed. That isn't it. It's more that when things are happening what can you do to get ahead of the feeling of like total nihilism and total, you know backed in a corner where your only response is the legal route or the exit route or whatever. And so what you're seeing here is definitely from lived experience. And in my humble opinion, I think that that's the best. Those are the best people to talk to because they've been in it, you know? And I used to feel very ashamed that we were in this lawsuit because it just feels like no one goes to med school and does all this work to go into a lawsuit. But my framing now is like I am here. I'm in this, I'm doing it. How do I help others avoid getting to this point? And how do I help others to not just survive in medicine but you know, I call it thriving in the last mile because I want you to thrive. You've made it all this way. You've gotten in, you're in attending, you're, you know, you're living your best life. How do you thrive? And these things, these different levels of maltreatment unfortunately deeply impact us. And at the end of the day, they impact our patients. Cause what served if I leave medicine, right? Like, how does that help anyone? And so that's really where it comes from. This is passion work for me. And if you hear that in my voice, that's cause that's exactly where it's coming from. Absolutely. And it's hoping me we can talk about more about that lawsuit when we stop recording and have the ethics fellows discussion. I bet you there'll be some interest but I probably don't want to have it on the recording that will be later. So let's just, there's one more comment is just asking if we have permission to use this as the faculty fellows who could not attend. And I'll just remind everyone in the audience that yes, on the McLean Ethics website, there is a YouTube channel and on that YouTube channel, you can access all of the talks that are recorded in this session. This one will be up later on this week and Dr. Sato has given us permission for that. So you can share it with faculty and trainees. So happy to do that. So with that, and it's coming up on the one o'clock hour I think we will stop the recording. And if you'd like to join, we have the ethics fellows who are going to be in a smaller group discussion. And I'll just remind you that next week again is Dr. Holly Humphrey, who will be here in person in P117 also on Zoom, talking about gender equity and medical education followed by Dr. Lanie Ross, who will also be in person back from New York, talking about publishing or perishing, women as authors and peer reviewers. And then followed by Dr. Karen Kim and gender equity and research who's in our provost office. So thank you for participating today. I think we need to still stop the recording.