 and medicine within our program in medicine and religion. He's an assistant professor of medicine in the section of emergency medicine and a faculty member of the McLean Center. He holds an MD from Cornell, completed his residency in emergency medicine at Rochester, and received a master's in healthcare research during his RWJ fellowship at the University of Michigan. He studies how religion-related factors affect health behaviors and medical practices of American Muslim patients and physicians. He also explores how scientific data can work in concert with Islamic moral reasoning and theology in the development of a comprehensive, theologically rooted Islamic bioethics. He's received a University of Chicago Templeton Foundation Faculty Scholars Award in religion and medicine and currently holds an ACS five-year career development award. Please join me in welcoming him to speak to us today on religion and workplace discrimination findings from a national survey of Muslim physicians. Awesome. Yeah, thanks. I also want to acknowledge, as Dan did here, that the work that I'm presenting was funded by the John Templeton Foundation. That's part of the Faculty Scholars Program within the program in medicine and religion and also the human capital behind this work. I see Ma here, I think, far left, but my co-authors have helped me put on this survey. So let's begin. I want to talk a little bit about the prevalence and predictive data on discrimination in the health care workplace. I want to talk a little bit about the social political climate affecting Muslims in the United States, describe our study, and then I'd like to open up some conversation around the ethical implications of the findings that I'll present. So you all know this, but the workforce diversity inclusion has been the mainstay for the last couple of decades and there are many different ethical underpinnings. One of them is about social justice, which is very prominent. The idea that there's historical marginalization of certain communities in the United States we like to provide them with equal opportunity for social advancement and this is one of the underpinnings of this movement. There's also a human rights sort of underpinning as well. There are also practical motivations around workforce diversity inclusion. From the patient perspective, you know, there's a lot of data on concordant relationships, right, similar to race, gender, ethnicity, and that those relationships between a doctor and a patient leads to increased satisfaction with care, more productive therapeutic alliances and due to these barriers to enter the health care system. It actually improves health care seeking behaviors. We also know that from the health care side, right, that it produces diversity and inclusion, produces a more welcoming environment for minorities. That increases productivity and satisfaction, decreased recidivism as well as job turnover. So there are both practical benefits from the patient perspective and the health care environment, not that we do this for those benefits, but there are some. So what do we know about discrimination in the health care workplace, particularly directed at physicians? The slide here has MDs listed, but some of the surveys have DOs as well. I don't discriminate, but my writing did here. But in any case, what do we know from Massachusetts? Well, there were 445 physicians surveyed in a representative sample of physicians in Massachusetts. We found that 63% of them report discrimination at their current workplace, and those reported significant discrimination were these groups, 60% of former medical graduates, 48% of racial minorities, and 43% of women. Moving from Massachusetts to a national sample, this is 529 physician sample through the AMA master file, with some oversampling through the national medical, NMS, the National Medical Society. And they found these findings here. Over one's career, 71% of African Americans reported discrimination, 45% of Asians, and about a quarter, a little more than a quarter for Hispanic Latinos, compared to 7% of whites. If you think about discrimination currently at their current workplace, again here you see high numbers, 59% of African Americans, 39% of Asians, 24% of Hispanics Latinos. Moving from that national sample of physicians to now a more select sample at academic medical centers. So you see here at US Medical School's 1833 faculty were surveyed, and you see here that 46% of the underrepresented minorities, being African American Latino, they were reported discrimination over their career, and about a quarter of the non, a non underrepresented minorities, particularly Asians. So that's what we know, that this is a phenomenon that exists. These surveys here, some are from the late, from the early 2000s, so they're a bit dated, but it's still apropos. So what are the known, knowns, and what's the unknown? Well we know that a significant number of minority physicians, be they from racial ethnic minorities, be they're women, or international medical graduates, they face discrimination currently or over their career. We know that discrimination leads to, out of the workplace, leads to increased job turnover, and decreased satisfaction and productivity. But do you know about any other characteristics of these physicians, aside from race and ethnicity or gender in this case? So I was interested with the aspect of religion, and the population I work on here, are American Muslim physicians. So what do we know about them? Well you know they comprise about 5% of the healthcare workforce, of the clinical workforce in the United States, and we know that most of the majority of nations are a key source of foreign medical graduates. So you see here Pakistan's number four, you know, Egypt's number eight. Number one is India, but know that 20% of the population in India, almost 20% is Muslim. So there's a percentage of those that are Muslim as well. They're a key source of clinical work in the United States. We know that from the Muslim community perspective that they're very active in the community. So Muslim doctors are the ones who fund a lot of the communal organizations in the Muslim community. They're highly religious, and we know that socially and culturally it's a very desired profession for Muslims, and when I was growing up and you hear these stories, you have two processions to choose from. You can be a doctor, you can be a lawyer. So that's how it works. Both deal with ethics, so it's good, so I'm here. But in any case, there's no national study of workplace experiences of this group, nor is there any sort of understanding of whether or not they're exposed to workplace discrimination. So why would that be the case? Well we know this, and I'm just gonna point some data here I think is important about the social climate that Muslims face in general. So this is from last year, 45% of respondents in a survey by Zogby held unfavorable views of Muslims. And Pew reported that Muslims are the most negatively-rated Muslim religious group in the United States. The FBI reports even after 9-11, there's an 800-fold increase in anti-Muslim crimes in the United States. So this is everywhere. My own mosque was shot at two years ago. So this is not some place in Oklahoma. This is even Chicago. Anyway, I didn't mean to get so, pardon me. And think about this, our presidential candidate, this was, you know, Herman McCain a few years ago. This is what he said about his doctor. I saw he had chemotherapy, had a surgeon. So I discovered that one of my surgeons' names was Dr. Dilla. I said to his assistant, that sounds foreign. He said, he's from Lebanon. Oh, Lebanon, my mind immediately started thinking, wait a minute, maybe this was just persuasion, it's different than mine. He said, don't worry, Mr. McCain, he's a Christian from Lebanon. Hallelujah, thank God. Right, so he was worried about a Muslim physician and a foreign medical graduate. This here was a very bad day when I saw this in JAMA, but this is a book that was profiled as an invited review, book review, in JAMA in 2008, Jihad in American Medicine, and talks about American healthcare facilities being the next ground zero. I saw the review and also the book talk about this, being suspicious. They talk about Middle Eastern physicians clapping when 9-11 happened, and that's the book, and that's in JAMA, that we were getting this invited review. Didn't point out that fact. Then you see in the BMJ here, radical Muslim doctors and what they mean for the NHS. So even within our premier journals, this idea of Muslims and Muslim clinicians being linked to terrorism is present. So our study here, main research questions, what is the prevalence of religious identity directed workplace discrimination amongst Muslim clinicians? And are there associations between physician characteristics, social demographic characteristics, but mainly resaucity is what I was interested in, and perceived discrimination? And so we can't get out of a national Muslim sample from the AMA master file because they don't record religious affiliation. So instead we use the Islamic Medical Association of North America, a partner on this study, and we sample from that group. Here are briefly the outcome measures. The main ones around perceived religious discrimination were adapted from racial discrimination measures that are out there and validated. We created some on religious accommodation at the workplace ourselves. These are the two questions. My workplace accommodates my religious identity, and I struggled to find time to pray at work. Then we had predictors that had to do with a wide range of religiosity measures, some leading to just this idea of importance. My religion is important to me, how important? Some about practicing prayer, fasting, food habits, and then some about appearance. Hey, Jabba, wearing a beard. So this was the group that responded. We had a 42% response rate. Mostly we found that they were middle-aged. They were men, mostly, 70% were men. The dominant ethnicity in this group was South Asian, 70% South Asian, 22% Arab. In terms of immigration status, this is interesting for all of us. Yes, two thirds were immigrated as adults, but you have some sense that they're also people born in the United States, as well as people who immigrated as children, 30%, 42% completed medical school here, and a third of them practice at teaching hospitals. So that's the sample. They're important to point out their religiosity. So when you ask the question about importance, this is what they describe. Is Islam the most important part of your life? 54% said yes, most important, some said, 30% said very, 10% said fairly. In terms of their practice, attending commercial worship, you see there's some variants here. Most of them strictly adhere to Ramadan fasting. In terms of reading Quran, again, there's some variants amongst that. About a half wore the hijab and a half wore beards. The interesting note here is that this is just slightly, just slightly, and I mean that, underscore that, more religious than the American Muslim population in general. That's opposite to what we find about physicians in the United States with other religious groups. So here are the outcomes. This is what I want to talk with you about. So the variable here is frequency of religious discrimination of a career, a quarter of them said sometimes and more frequently. When we tried to find a predictor from legiosity or social demographic components, we didn't have one in our data set. Thinking about religious discrimination currently at the workplace, 14% noted this. And the only predictor in our data set was people who responded this way. That religion is the most important part of my life. The odds ratio there is 4.1. When you think about the idea of common workplace relations and greater scrutiny at work due to religious identity, nearly half agreed with that statement. Again, the only predictor from our data set was those who believe that religion is the most important part of their life. When you think about religious identity influencing workplace relations with colleagues, this is a question, positive relationships, more than two thirds agreed with that statement that my religious identity positively influences relationships with colleagues. Those, amongst that was a predictor those who practiced had more practice space for jealousy. Reading more Quran or praying more frequently. So now about accommodation in general, these two questions that we came up with ourselves. 73% believed that their religious identity was a common at the workplace. And again here, the only predictor from our data set was individuals who felt that religion was the most important or very important part of their life. About prayer and struggling to pray at work, half of the respondents noted that. And again here, the negative predictor here, right? So those who believed religion is the most important part of their life had a lower odds of finding struggling. They were struggling to find time for prayer. But you also notice that people who worked at non-teaching hospitals or in a solo office, they had a lower odds of struggling to find time for prayer. So in summary, what's the good? The good is that 66% felt that their religious identity was a common at work and that it was a positive influence with colleagues. The problematic notion is that a quarter, one in four, encountered religious discrimination sometimes are more frequently in their career and 14% presently do so or at least report doing so. And half of the participant pool noted that they have challenges in trying to pray at work. So what's the paradox that I want to spend some time on with you? So you noted from the data set that individuals who feel religion is the most important part of their life when compared to those who feel it's fairly important had a higher odds of perceived religious discrimination at work as well as feeling that their religion was accommodated and a lower odds of having struggling to pray at work, right? How do you make sense of this? So here are some speculations. So first and foremost, if religious identity is at the forefront of one's sort of identity, so any negative experience might be interpreted as directed at that part of your identity, right? So if I am Muslim first, I am African American second, that when I have a net experience, I think about it as a Muslim first, right? Not necessarily, but maybe that's the reason. So I might have to do with the psychology of a response to bad experiences. On the other hand, you think about, well, physicians who feel Islam is the most important part of their life, they might be more attuned to conflicts between their faith and medical practice, right? Then when they try to talk about that, they might expose themselves to discrimination because they're drawing attention to this conflict. But at the same time, they might be more active in seeking out accommodations. I don't want to or I can't practice some sort of procedure. Well, how do we negotiate that? And I want to seek out accommodations because this is important to me. Now thinking about putting this all together, right? Since working in non-academic environments, solo practice in this case is also associated with less struggle to pray, perhaps most of the physicians who believe religion is the most important aspect of their life choose to leave or crowded out of certain types of workplaces, particularly the academic centers, right? So that's how you potentially can make sense of all of this. So my, the implications here, and this is a provocative implication I'm leaving at the end here. If groups of physicians, be they minorities racially or religiously, right, or both, face disincentives with respect to working in academic hospitals and discrimination, then both high quality patient care suffers as well as the mandate for social equity and social justice, right? And social advancement from marginalized groups. And diversity inclusion agenda, which religion rose out of a sense of racial and ethnic discrimination, then sexual orientation. We need to consider whether they should think of our religious diversity and sensitivity training in addition to just this racial, ethnic, sexual orientation that we have grown out of in the early 1990s and early 2000s. That's it. So let's talk. Thank you, Awesome, for a provocative paper. Any questions or comments? Looks like Mark is moving to the mic. Awesome, thank you very much. It's a wonderful survey. I couldn't help be struck by the lower level of discrimination against Muslim physicians that then against those three earlier surveys you showed in your presentation against other minority groups, racial or cultural minorities. That's one question. But the second question, Awesome, is whether anybody has done a comparable study, let's say on international medical graduates, I like the idea of Christians from Lebanon and Muslims from Lebanon, or Indian physicians, some Muslim, some non-Muslim Indian physicians, if that's been looked at, and whether the discrimination is against the religion that is Muslim religion, or just against foreign graduates. Very good, very good. So we, as I mentioned in developing these measures, we wanted to have people talk about religion. The survey talked about religious discrimination. You feel you treat differently because of your religious identity, not about racial, right? So if you think about the fact that we had four mega graduates in the sample, we also had minority South Asians. We wanted them to separate from, right? So when we did the pilot testing, and we did cognitive testing, people then would put religion up front. So when we had the survey, it talks about Islamic medical association, I'm trying to understand how Muslims are treated. So we tried to play that up because we wanted to talk about just religious identity, not the other aspects. And I think there is some intersectionality, right? So if you have a Muslim who's South Asian and a foreign medical graduate, there might be a multiplicative effect, but we wanted to separate that. So that's your right. So it's lower, but it's a different dimension, right? So we didn't ask them, are you also feel that because you speak differently or you're from a foreign country that you're treated differently, different job mask, we didn't ask that. So that's one thing. The second thing, I haven't seen a study like that, which you're suggesting, right? So to compare within the social groups, we tried to, in one area, there was Marcel Nunez Smith, who was one of my mentors, had done a survey and she found, the survey I mentioned here about racial discrimination, she found four of 16 Muslims reported religious discrimination, something like that. So if there was a very small sample, you can't make any distinction or many comparison. So. Mm-hmm, yeah. We're just gonna add to that discussion and say that in some ways it may be the case that race and one's language are readily apparent to people and then a signal for discrimination in ways that religion may have to have some other kind of signal for people to know what someone's religion is before they can discriminate and that may be another explanation for why the people who are prey more often actually feel more discrimination because they are actually signaling something that they have a different religion, yes. But I have no doubt that the response to the question might have considered, since the focus was on religion, that the discrimination they felt was religious discrimination. I'm only suggesting that there might have been a lot of other... That's correct, that's correct. That's the whole idea of discrimination research, right? When we think about this, how do you isolate a one aspect of one's identity if people's identities negotiate different things? But the fact that it exists and so the perception of that, they perceive this means that there should be some thought about a response, right? Whether or not it actually occurs, we don't know. Whether or not something's happening but either we can say it's their psychology and like I said, right, potentially or there's something about the system and the way they're interacting or others are interacting with them that draws out this sort of problematic notion. Okay. Well, please join me in thanking us. Thank you.