Our thanks to Dr. Jed Wolpaw and the Anesthesia & Critical Care Reviews and Commentary (ACCRAC) podcast for hosting a thoughtful discussion with Dr. Matt Wixson earlier this month.
The two discussed RADAR’s goals and how others can get involved, confronting implicit bias, addressing barriers to careers in medicine, and how departments can begin to effectively build positive cultures where everyone can thrive. Click the button below to listen or continue reading for the show’s transcript.
DR. WOLPAW: Hello, and welcome back to ACCRAC. I’m Jed Wolpaw and we have a fantastic show for you today. I have with me, Dr. Matt Wixson, who is an Assistant Professor of Anesthesiology at the University of Michigan. He’s also the Associate Chair for Diversity and the Director of RADAR. And I’m going to let him tell you what RADAR is, but Matt, I’m excited to have you on the show. Thanks so much for making the time.
DR. WIXSON: Thanks for having me Jed, excited to talk to you.
DR. WOLPAW: So let’s start with you. Tell us a little bit about you, how you got, where you are, what your practice looks like, and then tell us what RADAR is and how you got into the idea of starting this.
DR. WIXSON: Absolutely. So I’m a Michigander through and through. I was born and raised in a little farm town, south of the capital called Concord, Michigan. I’m one of seven kids. I am the middle child the only person who ended up in medicine, but a really, really big family.
And then I went to Hope College in Holland, Michigan, on the shores of Lake Michigan, which is near and dear to my heart. I sit on the Board of Trustees there and really my life trajectory changed there. I met my wife, decided to become a doctor, and kind of cracked on from that. After I graduated from Hope back in 2008, I went to the University of Michigan Medical School, where I graduated in 2012, stayed on for residency in anesthesiology, and then did a pain fellowship.
I like to joke that my practice — I did the pain fellowship and then retired immediately from pain clinic. I loved the fellowship, had an amazing experience, learned a lot, but just realized that I’m not a clinic guy. So I do get to do a lot of acute pain, which is really fantastic. And I’m on the orthopedic and ambulatory anesthesia team. So I do a lot of blocks catheters, taking care of high-level athletes, which is a ton of fun.
And then my, the rest of my time is spent working on diversity issues within our department and medical student resident education, which are really the things that make me come alive and keep me in academic anesthesia.
DR. WOLPAW: That’s awesome. Yeah, I feel the same way. It’s just such a privilege to get to work with our learners and try to do better with teaching and all the things that we get to do in academics that are so, so wonderful. So tell us about RADAR. What is, what does it stand for and then how was it conceived? How did you — tell us the story of RADAR.
DR. WIXSON: Absolutely. RADAR is a collaboration between our department and Wash U in St. Louis, the departments of anesthesia, and it stands for Raising Anesthesiology Diversity and Anti-Racism. So to go back about a year and a half now, Dr. George Mashour, who is the current chair of our department was named chair. And one of the first things he did was create a new position and appoint me to it as associate chair for diversity. These are issues that had not yet gripped the nation in the way that they have in the last year. But he had a vision for really transforming our department and transforming the field of anesthesia. And he wanted me to be part of that with them. And I will always be grateful for the opportunity that he’s given me. So he named me to that position and really said, ‘Matt, let’s do this thing. Let’s start changing the field.’ And RADAR was his brainchild.
We pivoted an NIH grant along with one of his collaborators, Dr. Avidan, who is the chair at Wash U, to think about how do we approach this in a systemic way? You know, we’ve been talking about diversity, both within the field of anesthesia, the field of medicine, greater society for a really, really long time. You can go back 20 years and it’s been on everyone’s radar, no pun intended. But then when you look at the data, things honestly have not really changed all that much. We, I was part of a paper a couple of years ago, looking at applicants into pediatric anesthesia fellowship by race.
And I want to make that point that when I talk about diversity it’s racial diversity, but there are other kinds of diversity too. And I think it’s important that we acknowledge that. And we talk about it. And actually that we’re really specific when we’re talking about diversity. So this is racial diversity and the paper, if you look at the graphs, despite there being more spaces available and more fellows trained, the demographic breakdown was essentially flat over 20 years. And if you look back even further from 1970s to now, there are less Black male doctors now than there were back then. So despite talking about it and thinking it’s important, nothing’s been changing. So RADAR is really designed as a mechanism to have a systemic approach to diversifying in the field.
DR.WOLPAW: Right. That is such an incredibly important goal. And is the idea kind of, obviously, recruitment, retention, promotion support? All of these things are part of this. Take us through that a little bit. Let’s start with the recruitment part. How, what is the idea of how to improve recruitment? Is it starting with just looking at medical schools? Is it, is it starting looking undergrad even before? Where are we starting and how do we promote that pipeline all the way up?
DR. WIXSON: Absolutely. Fantastic question. So when I think about RADAR, and if you spend time on our website, which is radaranesthesia.org, I think that’ll be in the show notes afterwards as well. It’s a three-pronged approach as we’re getting started.
First is thinking about that early pipeline. How do we create a pipeline that’s sustainable, it’s measurable and it’s actually going to make a difference? So that’s the first prong is high school, college, early medical students, both exposing them to the field of anesthesiology so that they can start to think, ‘Well, there’s an anesthesiologist. I didn’t even know what they did. That could be a fantastic career for me.’
So for example, we recently are engaging with a high school in Flint, Michigan, which is about 45 minutes from here. And we’re going to have a partnership with this high school where we’re going to start to spend time with the students, showing them what does an anesthesiologist do? Take them to the SIM lab for half a day, have lunch, talk about our jobs and how we got here, because it’s so important to be able to see someone who looks like you, who maybe had a similar experience to you in the field for you to then say, ‘Well, I can do that too; look at them. They did that.’ Obviously COVID had restricted our ability to have in-person experiences thus far, but that’s the plan is this fall we’re going to have 30 students interested in medicine from a high school in Flint come spend some time with us.
DR. WOLPAW: Clearly starting early, right? Because if we just start with medical schools, we’re already behind.
DR. WIXSON: Exactly. There are so many barriers, as you and I know, and I’m sure many people listening know to even getting into medical school. We wouldn’t have less Black male doctors today than we did 45, 50 years ago if those barriers weren’t real. And so how do you start addressing them early enough that you can make a difference? You know, some people would argue high school is too late, but that’s where we’re going to start because it feels manageable and something that we can actually do, and then we’re going to pilot. Okay. So what does it look like to talk to middle-schoolers? How do we, as anesthesiologists, get out in our community and show what we do and be a source of mentorship, sponsorship, inspiration?
I think it’s been easy in our field to say, “Oh, we’re just anesthesiologists. The patients come to us. We find out the day before who is on our queue. What’s our role in the community?”
And I would push back on that a bit and make the argument: We have a massive role in the community, especially as we think about being perioperative physicians. Thinking of all phases of care that we’re able to influence patient care, directly provide to them and indirectly shape policy, and move the field forward.
So that’s one prong of it is thinking about high school, college. So we’re partnering with the University of Michigan Undergrad Medical Society, again, to provide opportunities, to be involved with us, to shadow, to do research, things like that. And then we’re working with early medical students as well, because anesthesia is — you and I know — it’s the best job in the world, but most people don’t know about it until they’re M4s. And they’re like, “Oh my goodness, I can’t believe that I am here. This is the best thing ever.” That’s what happened to me. I had no idea I wanted to be an anesthesiologist. I saw it for a week. So that’s just so important to get out in front of early learners.
DR. WOLPAW: Yeah, yeah, absolutely. And I will echo what you just said, which is I have, every year I have at least one fourth-year medical student say to me, “Wait, Dr. Wolpaw, you’re an ICU attending. I didn’t know, anesthesiologists could be ICU attendings.” And I just want to like bash my head in because how are we not getting this message across? How, how is it possible? The medical students don’t know even what anesthesia is and what the subspecialties are and what you can do. We’re clearly failing to get this message across.
DR. WIXSON: Yeah, absolutely. So that’s one thing we’re working on. That’s kind of one prong.
The second prong, then, is thinking about our residents and our early career faculty. So often I think that we just have a lack of knowledge. We don’t know how to engage with what can be thorny and uncomfortable and difficult issues. And it’s hard to say, well, what’s my place in it? What can I do to make a difference? And whether that’s talking about diversifying the field — what is equity? How do I create an inclusive environment?
And then, also, we can talk a lot about health disparities. And I think you and I both know COVID over the last 15 months has just exposed health disparities that were actually always there. But now they’re in the mainstream. CNN is talking about it — major news outlets. You can’t miss the fact that Black and brown people are dying at a rate multiple times their white matched cohort. And how do we, as anesthesiologists start addressing health disparities? And again, I think for a long time, myself included, it’s easy to say, look, I just take care of the patients in front of me. I treat everybody the same or I’m colorblind. That’s another common, common phrase and I’ve grown and learned that no, we shouldn’t be colorblind. We should see color. And all that that is in that rich diversity, add both to our teams and to the patients we get to take care of and then start diving into that, leaning into that idea of no, as an anesthesiologist, I can make a difference.
Maybe I do treat people differently and I don’t even realize it. I mean, that idea of the unconscious bias that we all have, myself included. I’m reminded of that when I, when I look back and I’m like, man, I didn’t handle that situation very well; or, I wasn’t very thoughtful in my word choice there. And that’s something that we’re trying to provide to our residents and our early career faculty, is really training around unconscious bias. What are the things that you’re doing? How do you evaluate your practice as an anesthesiologist to make sure that you’re unbiased in what you do? How do we train ourselves to think about patients differently? We’ve all been that jaded resident or faculty who’s tired and can use language that isn’t thoughtful about a patient or we can dehumanize the patient to just “the patient with previa in room 12,” instead of understanding who they are, their specific risk factors.
That’s another area where I think as anesthesiologists we can make a difference — maternal mortality. It’s hard for me to understand how we’re one of the most advanced nations in the world, yet women and babies are dying at a higher rate than our match cohorts again. And then if you were to look at the Black and brown population, it is unbelievably higher. So how do we, as anesthesiologists, lead in that space? And RADAR is to help us think about how do we lead in that space? How can we, as the individual, contribute to the team and then to the field to medicine and ultimately patient outcomes? So that’s kind of prong two.
DR. WOLPAW: Yeah. And let me ask you, because I think this is so key. How do you, this is such a difficult thing, is teaching people about implicit bias when almost by definition, they don’t know they have it? I mean, if it’s implicit, then they may not recognize it. So how do you do it? Is it, is it sessions of training? Is it giving examples? Is it — how do you effectively help people recognize what implicit bias is? The fact that they may be part of, they may be doing it. They may be acting on implicit bias without knowing it, and then help them figure out ways to do it better.
DR. WIXSON: Wonderful question. I think there are a couple of different ways that you can approach this. And I think, as with many problems, you kind of have to have a multi-pronged approach to it.
One is formal training: What is implicit bias? It’s learning the language we’ve learned. So many speak, essentially, an “anesthesia speak,” a “medical speak.” There is a speak, as well, around issues of diversity, equity and inclusion, even understanding what those three things mean is so important. So I think formal training in unconscious bias — what is it, how am I contributing to the problem? — that’s all kind of contained in a formal course, I think.
But almost even more importantly, I think it’s important for leaders in this space and within departments to acknowledge their own biases, to normalize it and create a culture where you can feel safe actually making a mistake and saying the wrong thing or stating what I think that my bias is showing right now. For example, we really revolutionized how we interview for residency at Michigan. We now have a standardized team of faculty and residents who go through formal training around unconscious bias, best practices for interviewing — more, much more so than just the ACGME rules around what you can and can’t say, and things like that. And it’s created a culture now where, when we’re thinking about our rank list or discussing a candidate, our faculty members on the team — we call them FIGS, which is the Faculty Interview Group — will say, “I felt this interviewing, but I think that I may be biased in my approach.” And instead of it being a secret, shameful thing you need to hide or paper over, people now feel really comfortable saying, “I think that I might be biased in this; check me on that.” And it is revolutionized our culture. And I think that is what’s so important for senior leaders and for everyone to just feel comfortable saying: “I think there might be bias here.” That is, to me, the key.
You can go through all kinds of training. And I think that many health systems now are mandating it, search committees, need to go through it. And that’s one part of it. But more importantly is creating a culture where you can make a mistake. I think we’ve done an amazing job of that in anesthesia, where if you make a medication error or some other mistake, you don’t hide it. You come out with it, deal with it in the moment, you acutely fix the problem that you may or may not have been a part of. And then you do a review afterwards, again, in a way that’s not judgmental or to cause shame or embarrassment or have punitive damages, but to understand, “What do I need to do differently next time?”
DR. WOLPAW: Yeah. We look at the system. So I’m sure you’re doing the same thing. And we’re doing this too, is that we say, OK, there was an error and there are a minuscule percentage where it was something malicious. But that’s incredibly rare. Usually it’s because the individual meant well, but the system was set up for failure and we need to change the system. And so that’s the focus.
I agree with you. I think we’ve done a great job in anesthesiology in moving towards that approach. And it seems the same here.
You know, I think one of the real challenges is that you bring up, for example, the issue of white privilege and some white people get very on edge and they think, “You’re calling me a racist just because I’m white.” And the idea is no, no, it’s not your fault that you benefit from white privilege. I mean, you do, but it’s not, you haven’t done anything wrong by being white. You didn’t choose to be born white. But, you can acknowledge that you have implicit bias. Everybody has some sort of implicit bias. And it’s OK. And I love what you’re saying here, which is that culture making it OK to say, “Hey, yeah, like I have bias” — makes it OK to admit it just like a lab focusing on the system makes it OK to say, “Yeah, I gave that wrong medication. It happens to be in a vial that looks exactly the same as the one I meant to give. Let’s focus on that.”
So saying, “Yes, I have bias and it’s OK. That’s part of being human. I’m owning it. And I want to figure out how I can improve this and let it affect me less.” That has to be OK. If we make people ashamed to say, “Yes, I have bias,” or if we make people feel like by admitting they have bias, it makes them a bad, racist person — then we’re just going to alienate them. They’re going to disengage from this process.
DR. WIXSON: They do. And then all we do is lose any progress that we may have made along the way. You know, it’s interesting. You bring up the term “white privilege” and you’re right. It’s an immediate turn off for a segment of the population, both in America and the microcosms of our departments or our hospitals that we work at. And so it’s just so important to do exactly what you’re describing, which is saying like, “Of course you’re not a bad person because you’re white. Just like, I’m not a bad person because I’m Black and she’s not the bad person because she’s of Asian heritage, but we all have something that we do.” Similarly. I’m not a bad person because I’m a man, but have I held biases in thinking about women in a traditional role or putting something on them? Yes, I have. And then I had to apologize for it because I realized it afterwards. And it’s just, you just have to create a culture. And that’s where I think that that’s what RADAR is trying to do.
So our third prong is really targeted towards the senior leaders, the chairs and people like you, program directors who are part of driving that culture, of shaping that culture. To me, that’s what a leader does. Yes, they have very specific policy goals, departmental strategies, things they want to achieve. But to me, the best leaders have been ones that are able to set a vision and let those around them and who work for them and with them, get them there. And RADAR is pushing leaders to say, “How do you create that culture?” You know, for example, what about your policies? What about your systems have led to the state of where we are right now? So the racial diversity within the field of anesthesiology is pretty static over the past couple of decades. What about the way we do business has led to that? And then acknowledging that in a way that’s not threatening or shaming, but to say, what does it look like to do things differently?
For example the way we interview, we changed how we interview. We train people in how we interview, and then we have a more racially diverse intern class coming in this year than we’ve ever had in the past. So I would say our process was such that we were getting an outcome in the past, and now we’ve said our outcome: we’d like to have diversity — and again, racial diversity, socioeconomic diversity, geographic diversity, all types of diversity. So what do we need to change how we do to get that? And that’s where senior leaders make policy and decisions and can shape their culture that way.
And that’s the third prong of RADAR, is really targeted toward those who sit around the table that make the decisions to help make change and hopefully inspire them through the work that we’re doing and the resources we’re providing to say, “Oh, we can do that too. You know, Michigan did this. What if we tried that here?? Or UCSF is doing that?
And I bring up UCSF because they’re spotlighted right now on the RADAR anesthesia page for some programming that they’re doing. And that’s a way that other departments, listeners can get involved is let us know what you’re doing. RADAR is simply a vehicle for growth and for change. And it’s my goal is that it becomes a collaborative where institutions and departments around the country can say, “Let’s not reinvent the wheel. Let’s not live in our silos that we’ve always lived in.” And say, “Wow, that program over there is doing an amazing thing I think we could try, let’s try it.” So that’s one way that people can get involved.
DR. WOLPAW: Yeah. And, and so that’s amazing. And piggybacking off that, as you know, I put out an anonymous survey to listeners and to program directors in anesthesiology to say, “Hey, I’m interviewing Matt Wixson from RADAR. What would you like me to ask him?” And the number one, most common thing people said is exactly that: How can other departments other than Michigan and Wash U get involved in RADAR? S
o one obvious answer, which you just touched on, is go to the website and see what’s there. And it’s all kinds of resources you’ll see, highlighted programs that other people are doing. Is there a more formal way? Is there a more formal way for other programs to say or other departments to say, “We want to be a part of this”? Or is it is it more just like, “Hey, take advantage of the resources we’re putting out there”?
DR. WIXSON: Yeah. That’s a great question. And actually when you emailed me the other day, it kind of spurred me to think what does that look like? So I’ll take the easy answer, which is, I don’t know yet. You know, I think that a dream and aspiration of mine would be, we have departments that say we’re officially part of RADAR. Yeah. And then, but with that comes responsibility. Responsibility to share resources, best practices, highlight a unique program and kind of commit to saying, we too believe in this mission. We think that our teams will be stronger. Our learners will have a better experience. Our institutions will be more creative and innovative. And ultimately at the end of the day, we will take better care of patients if we have to get behind the idea that we need to diversify our field, but that, that matters.
So I would encourage departments right now to reach out to me, reach out through the RADAR website. So we can think about, what’s it look like to collaborate?
How can we be getting together at meetings —whenever we get to get together at meetings again, which I hope is soon — and brainstorm. I think it’d be incredible to have a RADAR brainstorming group at the ASA, where a bunch of people who are interested get together in a room and talk about, all right, what are we doing as a field? How can we nationalize our work?
Because the work is hard and there’s a lot that can be done. And at times I think that can be paralyzing. I know I felt that before, and I’m certain that others other institutions and departments feel that as well, where it’s, there’s so much to do that I can’t do anything. And if that’s, and if that’s our mindset 20 years from now, we’re going to look back and say, why haven’t things changed? You know, why have we not? Why didn’t we reach those goals we set for ourselves? By working together I think that we actually can start to move the field and it’s slow and steady progress.
I think one interesting idea — I sit in a group of other associate chairs who are really focused on DEI as well around the institution — is how do you sustain momentum? If you look back at the last year-plus, racial reconciliation has really been in the news. When you think about the murder of George Floyd. And really, I think that was a turning point in our country. And there have been many turning points in our country’s history. But that is one where front and center collided with the pandemic to say, we aren’t there yet. And we have a lot of work to do, but the fear can be that everything is just a flash in the pan. That it’s the right thing to do at that time. And so there’s a lot of momentum and energy and resources. And then six months later, it’s like, oh, we’re kind of just back to, we can’t keep it going.
Our goal would be that RADAR is a mechanism to keep it going. To have regular events and programming and engagement in addition to resources. So we can actually have that slow, incremental change. Maybe that’s my personality, but I believe deep down that it has to be kind of the slow and constant versus the big, big, big, and then nothing. You know, I look back at our launch, to me, that was a big, that was a big night. It was really exciting. And so it’s a combination of the two, but then how do we do the slow, steady work together to advance our field?
DR. WOLPAW: Yeah, absolutely. And I think so, first of all, I love the idea of RADAR as almost like an organization that provides, “Hey, you, if you want to be a part of this, here’s some things you need to do both because these are the right things to do.” And then it’s almost like group accountability. Then the people who are members hold each other accountable.
For example, the approach to interviews that you’ve taken, we’ve taken the same one. I’m having training for the people who are doing the interviews, standardizing the questions that we ask so that we can have a more unbiased approach. And then as you said kind of having this culture around being discussing how bias plays a role.
But you could have a variety of things that are kind of best practices that people would do as a way to be able to gain membership into it. So there’s lots of exciting things.
I want to turn back to your kind of prong one about recruitment and say, and touch on the launch event you guys had, which was fantastic. And for those who weren’t able to be there, it was this really wonderful panel discussion with a variety of folks, faculty and one, I believe, resident who was on the panel who, and she was just amazing. What an incredible woman, I don’t know her at all personally, but just from what the way … So eloquent, so incredibly — the depth of life experience and was just the things she said, it was like, I wanted to write them all down. It was just wonderful.
DR. WIXSON:Yeah. She is amazing. I always joke with her that I will be working for her someday, someday soon. And I believe deep down, she will be a chairwoman of anesthesiology, dean of a medical school, president of the United States someday. She is a remarkable individual.
DR. WOLPAW: Absolutely. And so, and I have been at a few different events. You know, we had a, for example, a screening of Black Men in White Coats here, which was fantastic. A lot of really powerful messages. So I don’t want to say for sure, I got, I’m remembering this from her, but I think so that she talked about her struggle, I believe to get into medical school. Is that right? And so I think a big part of it was scores. It was standardized test scores. And this, I think, and I want to hear your thoughts on this, because I think when we think about recruitment, right, this is such a key part that right now, and I hate that it’s this way, but right now the gatekeepers are the tests. And if you can’t score well on the MCAT, your chances of getting into medical school at all, let alone a good medical school are low. And if you can’t score well on your USMLEs, your chances of getting into the residency of your choice are much lower. And in anesthesiology, because of the basic exam, we’ve got this kind of built in barrier.
We can’t ignore scores, even if we want to, because if you can’t pass the basic exam, you can’t graduate and then we’ve not done you or us any favors. So how do we deal with — it’s great to get high school students interested in medicine — how do we help them? You know, you’ve got these amazing people, like the woman on your panel. That just clearly, I mean, as you said, she’s going to be whatever she wants to be — chair of a department, president of the United States. No question. And yet she almost didn’t even get to be a doctor because of the exam. So how do we, how do we get rid of that or attenuate that as a barrier to these amazing people, especially when we know from studies that have been done, that these tests are biased.
DR. WIXSON: Absolutely. It is one of the biggest things that keeps me up at night when I’m laying in bed, unable to sleep, to think about how do we go about this … What feels like insurmountable obstacle, to be completely honest. You know, obviously we’ve talked about the bias and the tasks, you’re a program director. I’m sure you think about the bias and step one and step two all the time. And I always say to medical students — I run our clerkship and do a lot of advising for them — is, especially if they come to me with a low step one, they say, can I be an anesthesiologist? And I say yes, you can. When I’m working with residents, I promise you, I have no idea who got a 280 and who got a 195. I honestly could not tell you who did what on one of these standardized tests.
So the question is, how do we start pushing back against these gatekeepers? Step one is going to go to pass, fail. I’m sure that’s something that keeps you up at night is how do you start screening? Because for better or worse, they’re used as gates. How do you — you can’t look at 5,000 applications. So how do you start thinking about creating the class, attracting the class, recruiting the future of anesthesia, but getting rid of some of these biased gates?
I think one thing you have to think about is it’s going to be more intensive. And when I say intensive, it’s going to take time and it’s going to take money. Because time is money. Money is time, however you want to say it, you’re going to have to screen people differently than you’ve done before. We are going to have to screen differently. And by screen, I don’t mean screen in or screen out, but try to figure out who you want to interview. You can’t interview everybody. So how do you approach that?
And one of my fears is that programs will just start moving to step two as the new gate, because it seems too hard to try to figure out a different way to do this. But I would say, start thinking now about what are the ideal attributes? How could we leverage technology to start thinking about how to screen using something they write? Their own words as, oh, they’re highlighting themes that we think are important. And maybe they’ll gel in our program. Because every program has got a feel, it’s got its own goals and many of them are the same, but some of them, some of them are different. And then I think it’s asking the question, why do we have this test? If step one was initially kind of created as a competency exam not a knowledge exam — I couldn’t tell you how it’s scored. I don’t know if the difference between a 220 and a 260 is two questions or 25 percent of the test. I literally have no idea. Do you know, do you know the difference?
DR. WOLPAW: No idea.
DR. WIXSON: And so how do we start having that conversation to say, OK, let’s maybe take the curtain down a little bit and understand what’s the motivation behind it. Similarly for the basic exam, I was in the first cohort to take the basic exam. I’m pleased that it’s a pass/fail test but are we tracking, then, the outcomes to say that we’re getting safer clinicians, that our patient outcomes are better because we’ve added the basic exam and if five or 10 years from now, we can’t see a difference, then I think we need to be able as a field and as a accrediting body to say, is this the right thing to do or not?
DR. WOLPAW: Absolutely. And I’ll tell you, every time I talked to folks from the ABA who were involved in this testing, I bring up a couple of things. One is how do we justify a standardized test as the gatekeeper, when we know they’re biased? And when we know it forces us — for an anesthesiology program to take someone who scored a 195 on step one is to say they are at high risk to fail the basic. So they may be the most amazing person you’ve ever met, but they may not be able to pass the basic. They might be someone who could be the best doctor we’ve ever had. And yet if they can’t pass the basic, they cannot graduate from residency. And so that’s a huge problem.
So what do you do as a program? We’d love to ignore that score. We’d love to say who cares? It was 195 they passed, but if they can’t pass the basic, then that’s a problem. So how do we justify it?
And number two, we’ve gone to this great system, I think, for faculty, in MOCA, where it’s not a big high stakes, every 10 years giant exam, it’s this ongoing MOCA minute. These questions where as long — even if you get them wrong — as long as you learn from it, you get to see the question again, down the road. As long as you show you’ve learned and improved. That’s great. You’re not, you’re fine. Right? Why isn’t that true for residents too? Why do we make residents take some big, giant high-stakes exam that’s more dependent on their ability to take standardized testing than it is to actually have the knowledge when we have this other system that to work great? And I really hope they’re starting to consider that. And that maybe we’re going to move to a place where we have put less emphasis on these standardized tests that they clearly, more than anything else, test how good you are at standardized tests.
DR. WIXSON: Exactly. And that’s the problem when you’re talking all the way back to high school is, to me, what a standardized test shows me is that you’re good at taking standardized tests. That’s all it is. And I think there’s an — what we’re losing in that is trainees and learners really learning to pass a test, not learning to be a better doctor. And we’re using medical assessment that doesn’t reflect the reality in which we live now, which is if you’re in the ICU and you can’t remember something, you probably pull out your iPhone and Google it really fast. There is an inability for the human brain to hold everything in it. We just can’t do it. And so why are we assessing people based on kind of a notion that they should be able to recall all these things when you can look up that equation? And it actually reduces the risk of error if you look it up.
DR. WOLPAW: Yes. We want you to look it up.
DR. WIXSON: Or pull up the calculator, we want you to look it up. And so I just think that we’ve got to move past this system where what is valued is an ability to answer a multiple choice question — and really then deemphasizes creativity, innovation, resourcefulness.
Ten times out of the 10, I would rather work with a resident who got a 200 on step one, but will show up every single day for work thirsty for knowledge and so focused on patient care. That’s who I want to train. That’s who I love up working with. That’s who I feel inspired by and I learn from — versus the person who everything’s been super easy and they kind of have this mindset of I’m studying for the test because I need to do well on the test.
It feels to me, deep down, that all these things are starting to come to a head. Maybe that is youthful ignorance here that I think that we may have some change. But I sit on the admissions committee at the University of Michigan. And again, these conversations that we have are different than I think they were even 13 years ago when I was applying to medical school, 14 years ago.
Here’s something I don’t talk about very often. I did not do well on the MCAT. I just, I didn’t, and I didn’t have time to take it again. And I’m the first in my family to go to college and didn’t have anyone around me really, who was like, “Hey man, you should, like, maybe take a gap year and take this again, or try to do some research.” Or something like that. I didn’t have that luxury. I didn’t — I couldn’t afford to just take a year and maybe do an unpaid internship or something like that.
And I feel very fortunate that the University of Michigan kind of looked at me and said, “We think you have it. Yeah, you didn’t have the best day there, but your cumulative record in college shows that you’re creative and innovative and a hard worker. And we think you’re going to add to our class.” And I would say the rest has been history and I have been very motivated by that actually.
And I like to share that story because again, in medicine, we don’t like to talk about the things that we didn’t do very well. So similarly is where we’re discussing feeling embarrassed if we say the wrong thing, we feel embarrassed to let on that we don’t have it all together or that we didn’t do well sometime, but by people being honest and vocal about that, I think it can be so inspirational for someone five or 10 or 15 years behind them to say, oh, they didn’t do well on this thing and they are doing amazing things now. But it takes a level of vulnerability that I’m not certain everyone wants to have, but the more that we do it, I think again, the more we’re going to change the culture of our departments.
DR. WOLPAW: Absolutely. Well, first of all, thank you for sharing that story. And I couldn’t agree more that the only way that we are going to combat imposter syndrome, which is so prevalent in medicine, is exactly as you said: to tell the stories of when we didn’t know, when we made a mistake, and to admit when we don’t know. And it has to start from the top. If you, as a faculty member, are willing to say to your residents, “I don’t know the answer to that,” or, “I was wrong about that,” then they’ll feel a little more comfortable when they don’t know. And I think you’re just exactly right. That’s so, so important.
I want to ask you — let’s go back to kind of the second prong for a second. And you mentioned, and I completely agree, that having training for folks so that they know the vocabulary, they know what implicit biases, they know what microaggressions are — that’s so important.
There’s some data out there that suggests that when you make these sessions mandatory, it can actually produce the opposite result. That you can end up with people who are resentful and therefore they are more likely to engage in these things. Do you have a feeling on that? Should these things be mandatory? Should they be optional? How do we approach them?
DR. WIXSON: Wonderful question. I think that they should be mandatory in certain situations. So for example, if you are going to be part of a committee that is making decisions that is steering the department, that is recruiting the next generation, I think that you need to understand how the process has to be different than it’s been in the past. So for me, that’s it, that’s kind of an easy one to say, it’s mandatory. And if you don’t want to go through that, if you don’t believe in it, then you’re not going to have the opportunity to be part of the shaping. You know, it’s personal choice, kind of, do what you want to do; but if you want to be part of this leadership role, you’ve got to understand that.
Because to me, the data is pretty overwhelming. We all know deep down that we have biases. And then we can all look back in our history and come up with an example where you made a decision or made a comment that was based on one of those biases. So to me, that’s a settled fact. We don’t need to argue with all that much.
For the broader department, I think it’s more nuanced. I think that it should be encouraged. I have read those similar studies about people kind of doubling or tripling or quadrupling down. Well, you can’t tell me that I’m this, I’m not that. And it being harmful. And I think we need to understand that signal that we’re hearing and to encourage people, to try to understand that.
And it goes back to that idea of what culture do we want to build? And it’s going to take years to start turning these giant Titanic-sized ships, departments, institutions, but you’ve got to start somewhere. And so you make it something they can learn from. And I think, again, when leaders are honest and open and vulnerable, that’s inspiring. It’s “Come along with me,” not, “Go where I tell you to go.”
DR. WOLPAW: Yeah, yeah. That I think is so key and we’ve taken the same approach. So Hopkins — for clerkship directors, for program directors, on institution-wide — it’s mandatory to do implicit bias and microaggressions training. We make it mandatory for all interviewers, as you, I know, have. So I think you’re right. Those people who — they can opt out, you don’t have to be an interviewer. If you’re going to be an interviewer, you need to do this. I think that’s totally fair. And honestly, in my experience, nobody is resentful of that. They understand why this is important and they engage. So I love that.
Let me ask you I have a couple more kind of audience questions that I’ll ask you, but let me ask you first, are there any kind of common questions — and I know RADAR is young, it was only launched recently —so, but in the time you’ve been involved in this work, are there things that come up commonly? Do you get asked questions by whoever — people who visit the RADAR website, who attended the launch, just people who are interested — that commonly come up that would be interesting to address?
DR. WIXSON: I do. There were a couple of themes that come across. I think we’ve touched on one is how can we be involved? And hopefully we’ve impressed upon, like, we just want to hear from you — email me, tweet at me, show me what you’re doing. Let’s think of ways that we can create an online collaborative. And while COVID has had so many downsides, one of the positives is it’s normal for us to all get on webinars now. Our access, our reach is so much greater than it has ever been before, than I think any of us would have thought of even 18 months ago of let’s host a webinar. Myself, I would have been like, “What? A webinar? I don’t want to get on this thing. You know, maybe I’ll watch it later.” It’s just different, we’re interacting differently. And I think that that actually adds to the richness and the depth of our interactions and our collaboration.
So I think that’s one thing is let us know what you’re doing so that we can publicize it, so that we can develop strategic alliances and collaborations and think about how to work together and really move the movement forward. So that’s one thing.
I think the other common thing I hear is I don’t want to do it wrong. And I then say back, what is “it”? And they say, well, DEI. And I say, OK I think first off, thanks for being open to saying that. I think that’s a really hard thing to verbalize is what do I, as a cisgender white male, have to do with DEI? How can I speak into that space? And I say first off kudos for wanting to be involved, for understanding that you may not have experienced certain things, but you want to help move this forward right? You recognize the inequities that exist and you want to be part of the solution.
So I hear that and I applaud the sentiment and I then just provide some reassurance of you will do it wrong. I have said the wrong thing, thought the wrong thing, thought I was nailing it out of the park. And then nope, that was not right. I was insensitive. I was X, Y or Z thing. And just normalizing that, just like everything else we do, we’re not going to always be perfectly spot on. And just accepting that and understanding how in yourself, you can kind of deal with that and move forward. Or you can say, “I’m sorry I said that.”
You know, I can think back to interviewing this past year, this incredible applicant. And I asked her a question, and then in her answer, I realized that I was holding a bias about women and their role in the home. And I instantly felt very embarrassed. I’m the associate chair for diversity. I’m supposed to have figured all this out and really been the person, this shining example. And I messed up and I immediately apologized to her and said I was holding a bias that I clearly have in my response to you. I’m sorry. And she was incredibly gracious. And our interview concluded fine and I don’t think any harm was done, but then I use that example and I share it broadly. I say to people, this is something I did and I did it wrong. You’re going to, it’s OK. Learn from it and kind of move forward.
And also verbalizing, I don’t know what your experience has been. Can you tell me what it’s been like? You know, I’m not a woman, I don’t know what it’s like to be a woman in medicine. So how can I ask that question of you? And you can share your story with me and I can start to get an understanding, knowing that I will never know what it’s like to be a woman in medicine, but I can understand parts of the story and I can reflect on what are the things I do that may make their role in our team harder. You know, I regularly check in with our trainees and say, what’s it like being a trainee now, I haven’t been a trainee for five years. What are you stressed about? Again, knowing that I was in their role at some point, but I’m not anymore. Things are different. I think that is kind of a blueprint or a framework for how you can interact with people who are different than you, and try to make them feel validated, sponsored, mentored and really empathize with their position and learn from them.
DR. WOLPAW: Yeah. I think that’s so powerful. You know, it’s really hard. I think sometimes you’ll have someone that’ll come and say so-and-so said this thing and it offended me and now I don’t ever want to be around that person again. And while I’m sure there are people out there who are intentionally doing stuff. It’s way more common that they had no idea. They had no idea. And so I think that it’s incredibly hard. As you just touched on, like, I can never know what it’s like to be a woman at all, or to be a woman in medicine. I can try to learn from the women in my life. I can never know what it’s like to be a non-white person, but I can try to learn from the people I know. But I still will never experience it and I’ll never know. And so it’s incredibly difficult. And I know that this has come up amongst other white folks who have expressed, who have written in to ask questions. To think, I feel like it’s not my place to say to that person, “Wow. You know, give them another chance. Or maybe it wasn’t intentional.” Because people are afraid of defending someone who has done something, who has expressed bias. So it’s, I don’t know if you have any advice for, I guess, for white people or for men who want to try to promote the things you’re saying, but are afraid of being tarred with that same brush of negative bias. If they try to promote the idea of, “Hey, let’s give people a chance. Let’s try to be, let’s try to teach rather than ostracize.” How do you, what do you recommend?
DR. WIXSON: It’s tricky. It’s hard. It’s really, really hard. You know, an example I would use, though, is first reflecting in yourself, figuring out your biases and figuring out how you can start to work to correct them. And what are the little things that you can do day in and day out that will start to elevate the culture and change, change your microcosm you live in.
So, for example, I refer to all my trainees when I’m talking to patients as doctor. Here’s Dr. Snarksis, here is Dr. Vu. And whether they’re men or women, it’s the same; because, you and I know, and everyone listening knows that women are treated differently in the hospital. Patients treat them differently. Similarly, my trainees who are Black or brown or minoritized, same thing, I always use doctor.
So I’m using whatever small political clout that I have to ensure they are on the level playing field. And if a patient says something or calls them by their, a trainee by their first name and they haven’t been invited to do so by the trainee, I will correct them. And it’s uncomfortable. It doesn’t happen all that often, but that’s an example of something little you can do day in and day out to promote a culture and to start to build that reputation. So people know they’re not messing around here. You know, they believe in this and they’re willing to speak into an uncomfortable situation to try to right a wrong.
Now to answer more specifically your question how do I not appear like I’m defending them is my advice would be to say to the person who is offended or hurt or upset, how can I support you in this? And have them reflect back to you, really, what they’re looking for. Maybe what they’re looking for is you to facilitate a conversation between the two of them, maybe they just needed to vent, or maybe they’re looking for you — that’s an opening for them to then say this has happened five times with this person over the last year. I specifically asked them not to make that comment, make that joke, call me XYZ and they keep doing it. It’s an invitation for them to open up to you because maybe it was a one-off or maybe it’s a pattern that you can speak into and you can, again, use whatever position or privilege or power that you have to help right that wrong.
And I understand the sentiment of cancel culture. If you say one wrong thing, then you are forever banished. And to me, that’s scary too, because I say wrong things. I mess up. I don’t want to be banished. I know my heart, I know my positives, I know my weaknesses. And so again, trying to just normalize making a mistake and then it’s up to senior leaders, the department as a whole to say, who do we want to be? What are our core values? How does this incident match up against what we say is our core value. Egregious things are egregious. And deep down we all know a truly egregious thing when we hear it, when we see it. You get that feeling in the pit of your stomach of, I can’t believe that just happened.
DR. WOLPAW: Yeah, I completely agree. And I think it’s so easy to — we hear, for example, sometimes the nurses do X, Y, or Z. And I try to emphasize that while some nurses may do what you’re describing and I’m sure you’ve experienced it, we want to be very careful. Because not all nurses and we know there is no “the nurses,” right? There are people, these are people, some of them have different biases than others. Some of them may act more commonly on their biases and may need more help to realize that and to change. But no more than we would like to be said “the anesthesiologists” all do X, Y, or Z, or “the residents” all do X, Y, or Z. You know, nobody wants to be lumped into a group and labeled as all people in that group do X, Y, or Z.
And so I think a lot of this comes down to being willing to see people as people who are flawed and who most of the time are, if you have an interpersonal interaction, if you’re willing to have a conversation and person to person are willing to see things from another perspective, not everybody, but a lot. And I think we need to back off of the idea of labeling groups and saying they do this.
And saying, OK, I had this interaction with this person. I want to talk to them about it, or I need help to talk to them about it, or I’d like you to talk to them about it. But having that, that’s how people learn. People learn from realizing that their actions impact real people. And those people have — if you hear about it from that person, it’s way more powerful than being forced to take some training. If somebody sits down with me and says, “Hey, when you said this, it made me feel this way.” Wow is that powerful. I may not have realized it, but oh now I see it and it’s real. And I see how it impacted you as a person. And that brings it home. And I think that’s really key to try to facilitate those conversations.
Yes. The cohorting is so dehumanizing. And I think it’s a defense mechanism because we don’t want to do the uncomfortable, awkward, hard work of what you’re describing — that conversation. Because it’s so uncomfortable. It’s so uncomfortable to have to sit down and say to someone, the thing that you did or said, or didn’t do, or didn’t say hurt me — because it’s showing vulnerability. And I think if we could just all show a little more vulnerability and humility — what a different environment in which we would work and learn. And for our trainees, they’d be able to see it modeled by the faculty member of apologizing and saying I got upset there and I shouldn’t have, or I talked about a patient in a way that was, again, dehumanizing — “the colon in 28,” not the patient with colon cystitis in OR 28.
And it’s such a small little thing, but it’s so powerful. And it’s those small things, again a long time ago, we talked about how it’s the slow, steady progress. It’s the small words and how we talk and how we interact with people that makes the lasting change. Not the big one-time, this is it. Now everyone be different. That’s not it. And so that’s something you can do. You can start modeling that for the people around you, how you’re talking about people, how you’re saying — I just think that’s such a great example of a nurse did that to you, not all the nurses; or the doctor said that to you, not all nephrologists.
DR. WOLPAW: Right. Yeah. No, I think that’s — I couldn’t agree more.
We’ve covered almost all the audience questions in everything we’ve covered already. One other that I think is interesting that I’d love to get your thoughts on. So a few people wrote in, and again, this was anonymous, so I don’t know, but I’m assuming these are white male program directors who are saying, OK, I’m trying, I’m in tune with this. I believe it. I know bias is out there. If I get a negative evaluation about a woman in my — a female resident — my program, or an underrepresented minority, I know that that may be fueled by bias. It may be influenced by bias. And so I’m going to take it with a grain of salt, but there probably is a point at which they’re just like white residents — may actually have true struggles. It is possible, of course, for women or for underrepresented minority residents to have struggles, to be doing something that needs improvement. So how do you know when to kind of say, OK, this isn’t all bias. There’s enough of these, or it’s coming from enough diversity of faculty that this is probably something I need to act on. And then how do you address it with that resident without being labeled as someone who is acting on bias?
DR. WIXSON: It’s a tough situation and I see both sides of it. Yes, not everything is bias, not everything is racially motivated. Not everything’s motivated by gender or whatever type of diversity you want to talk about. It’s not all bad.
But on the other hand, if you look at national data around the residents dismissed from residency, which you’re a program director, that’s a really big deal. Every single spot is desired, is recruited for — there’s a lot of forward momentum to make people successful in residency, help them be successful and graduate them to join the workforce that we desperately need. We have an unbelievable physician shortage. We have an anesthesiologist shortage. So every spot really matters. So if you look at the data of the residents who are dismissed nationally from all training programs, there are some fields in which up to almost 50 percent of the residents dismissed are residents of color.
And I would say, that’s not an accident. You can’t have your workforce be 6 percent underrepresented minorities, but make up almost 50 percent of the residents who are dismissed. That’s a problem.
So I think my suggestion for that program director would be, what’s your evaluation process like? What are objective measures and what are subjective? How do you take the time to reach out to the faculty member who writes that negative evaluation? And I think this should be for actually for all residents.
Create a process for residents in which you’re evaluating a negative evaluation and say, walk me through, walk me through this. You know, what did they do? And if what you’re hearing back is, well, I just think they didn’t have a good attitude that day. You really have to steer the conversation to the objective, not the subjective. But that takes time. It’s a lot of work to do that. I can only imagine the amount of work it takes, but I actually think that’s really important because is it a lack of knowledge on the resident’s part that they’re unable to — they don’t know the doses of induction drugs? You know, to me, that’s a discrete problem we can fix. Is it that they need a reading plan? Are they struggling with time management? Is there something going on at home that you didn’t know about? These situations are really, really complex and you have to remember, you did recruit this person at one point. They’ve been through all these gates, all these gatekeepers, and yet somehow they made it despite a lot of challenges along the way, potentially. So to really dig into the situation.
And if it’s a one-off bad evaluation I think if I’m reviewing a medical student evaluation, it’s like, oh yeah, they had a bad day. They didn’t gel. That’s normal. Those kinds of things happen. But take the time to reach out. Especially if you start seeing a signal to say, what is this? And we do root cause analysis all the time around an operating room mistake or a bad patient outcome — approach it the same way. What are the root causes here? And if it is — I just believe deep down those signals are going to start showing up if a faculty member X routinely rates your residents of color or female residents or XYZ resident lower than their mean. Use data. Then you have to say, I see this signal here. What do you think? Have them reflect on it.
Similarly from the resident’s perspective, if they’re getting, if it’s that situation you described where they’re just clearly behind their cohort ,having a conversation with them and saying these are the objective data we’re seeing. Here is the subjective comments we’re getting. What’s your reaction to that? And it almost takes you out of being the judge and the jury and makes you a facilitator of self-reflection and growth. And I think that by doing that process, which again is messy and uncomfortable and awkward, you can actually start to get to what’s really going on deep down instead of just saying, oh yeah, that attending is kind of racist. They just, that’s how they are with those residents. Like, it’s no one you would want to have in your department. And, as we’ve talked about, most people aren’t blatantly racist. It’s that they are not anti-racists, that they’re not working toward eliminating racism, they’re neutral, they’re Switzerland, and that you can help them grow in that and say, this is a signal I’m seeing. Have you, what do you think about that?
DR. WOLPAW: Yeah. That’s fantastic advice. Thank you, Matt. So I know I’ve taken a huge amount of your time. Let me just ask you, is there anything we haven’t touched on that you want to touch on before we move forward?
DR. WIXSON: I would just thank you for the opportunity to talk about this and really provide a word of encouragement that the progress is real, but it’s slow and steady and that can be OK. I would recommend to people that it’s going to take all of us — there are certainly people of color who aren’t interested in being the face or the driver of this work. So that’s OK. You know, don’t make the assumption that, well, well, you’re Black and in medicine, of course you want to be involved in this — you know, develop structures and systems and committees that are diverse and can work together moving us forward. And just lastly, that RADAR is in its infancy, but I believe deep down that it could have the power to really transform our teams, our departments, our institutions, and I’m excited for people to partner with us and be part of it.
DR. WOLPAW: Fantastic. We are excited as well and thrilled that you’re doing this, and I can’t be grateful enough that you took the time to come on the show. So thank you.
Let’s turn to the portion of our show, where we make random recommendations. Do you have something that you’d like to share with the audience? Something you’ve been checking out lately that you’ve been enjoying?
DR. WIXSON: Yes, we are big fans of The Handmaid’s Tale. So I don’t know who listening is a fan of that. If you haven’t checked it out, it is incredibly dystopian and every, every time, oh, that was just intense. But season four just came out. So that’s been our jam lately is staying up too late at night, eating popcorn, watching The Handmaid’s Tale.
DR. WOLPAW: I couldn’t agree more. My wife and I have watched every episode, although we’re just now catching up with season four so far, but it is, it is such a disturbing show, but it was so well done and it really makes you think.Yeah, we’ve really enjoyed it too.
I’ll recommend if you haven’t checked out — HBO did a documentary called Tiger about Tiger Woods and it’s just a two-part documentary about an hour and a half each episode. So it’s about three hours total and it really is well done. It highlights how disturbing and difficult his life was in terms of you know, growing up with the pressures that were put on him from really about birth. And also kind of reminds you how unbelievably dominant he was at the time — kind of late nineties, early two thousands — and how the pressures of celebrity and all that play in and how frail people can be and the mistakes people can make and it’s well done and I think worth a watch, whether you like golf or not. Soi recommend that too.
Matt, thank you so much for coming on the show. I am just incredibly grateful and I think this’ll be a really powerful episode for people to listen to, and I’m sure people will want to get involved in RADAR.
DR. WIXSON: Thanks so much for having me.
DR. WOLPAW: All right, that was fantastic. What an interesting and deep discussion. I really hope that you all got as much out of that as I did. Let us know what you thought, go to the website, accrac.com. Leave a comment. Others can learn from what you have to say. You can also join the conversation on Twitter. I am at Jay Wolpaw and we’re @accracpodcast. And of course you can join the Facebook group and participate there. If you’re a fan of the show, please consider going to Apple podcasts or wherever you get your podcasts and leaving a comment and a rating — it really helps others find the show. If you’d like to support the making of the show, you can go to patreon.com/accrac, that’s P A T R E O N.com/A C C R A C, where you can become a patron of the show, even if it’s just a dollar or two that you pledge, it makes a big difference. And we really appreciate it. You can also make individual donations anytime by going to paypal.me/accrac or looking for Jay Wolpaw on Venmo. Thank you so much to those who have already become patrons and already made donations. We really appreciate it.
Big thanks as always to our fantastic team. Dr. Bryan Park is our tech lead. April. Lou is our social media manager and Dr. Kimia Cash Cooley is our former social media manager, who’s still helping out with the show. Our original ACCRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com. All right. That is it for today for the ACCRAC podcast and Dr. Matt Wixson, I’m Jed Wolpaw. Thanks for listening. Remember what you’re doing out there every day is really important and valued.