More than 250 people joined us for the launch of RADAR this spring as we discussed the need for greater diversity within anesthesiology, the barriers to diversifying the field, the challenges of being a minority in medicine, and what it looks like to be an ally.
- Moderator Matthew Wixson, M.D., Clinical Assistant Professor of Anesthesiology, Associate Chair for Diversity, University of Michigan
- Allison Mitchell, M.D., Assistant Professor, Associate Program Director for Anesthesiology Residency, Washington University St. Louis
- Peter Knoester, M.D., Anesthesia Practice Consultants, Grand Rapids African American Health Institute Advisory Council
- Brittany Ervin-Sikhondze, M.D., Anesthesiology Intern, University of Michigan
We want to thank our incredible panelists and all of you who tuned in, listened, engaged, and asked questions. We couldn’t answer all of the submitted questions live, so Dr. Wixson has answered more of your questions below.
As an incoming resident that is a white male, what is the appropriate way to support colleagues and call out microaggressions that are all to come? As a medical student, always being at the bottom of the power structure makes me feel so powerless to affect change for fear of retribution.
As an incoming intern or resident, it’s important for you to understand that you actually do now have power and privilege as a physician working in a health system. Figuring out how exactly you can utilize that power is important — and it’s going to be hard at first to speak up when a patient may say something that’s inappropriate, or your colleague or your attending says something that makes you feel uncomfortable.
Be direct and try to keep emotion out of it: “I think that comment was inappropriate,” or, “That comment made me feel uncomfortable.” Often when people say things off the cuff, they realize they might have sounded wrong. As such, we can approach it with some level of grace but also acknowledge that what was said wasn’t OK.
If your initial feedback is received poorly, what are the mechanisms in place to escalate it? Here, again, it’s difficult to think about this next step because of a fear of retribution. And you might think it’s easy for me to say this because I’m not a trainee anymore but this concern can come up at multiple levels or career stages. It can be hard for someone in any position to speak up, but we have to understand that this is our responsibility.
Are there policies we can put in place to encourage allyship or the ability to “speak up”?
You have to think about your structure and how your policies will or won’t promote a culture of allyship.
One question to consider: Do you have systems in place to allow for speaking up? Do you have anonymous reporting? Do you have someone who functions as an ombudsperson — or someone who’s a neutral arbiter who is respected, has knowledge and can be a person that people trust, in whom they can confide? It’s important to develop that role as you’re starting to grow and change the culture of your department. Identify one or two key people that others in the department will feel comfortable in going to for these difficult conversations.
And we need to equip these people with the knowledge and the skillset and the ability to get things done. This can’t be an empty position where people come to them and the response is, “I’m sorry to hear that. I can’t really do anything about it.” They have to have the support of leadership at the highest levels.
I commonly hear amongst colleagues a sense of denial — the whole, “Well, I’m not biased,” and, “I treat everyone equally.” How do we get around this prevalent sentiment and try to acknowledge the biases that we carry?
It has to start with some personal reflection — who you are as a person and why you may think the way you think. It’s a long journey. It’s not something you can do in a two-hour session.
We can use materials and resources to help us understand where our blind spots may be, whether that’s an implicit association test or a structured unconscious bias course. And then we need to be open, honest, and vulnerable about our biases — naming them out loud and calling ourselves out in certain situations.
How can we help others in our department start to recognize their own biases? Again, it goes back to the culture, creating an environment where we normalize this ability to recognize and address our own biases. We have to move from this culture of shame when we make mistakes to a culture of improvement. People make mistakes; acknowledge it, recognize it, apologize, learn from it, and move forward. People are often afraid to get into the muck with some of this work for fear of “doing it wrong.” This can result in people who could make contributions instead sitting on the sidelines forever… and that’s not going to be helpful.
One of the issues we are struggling with is attracting URM residents. One issue is the composition of the residency program and the department overall. Another colleague and I have started having small group meetings with the URM medical students and residents (which are few). We want to provide a supportive environment. Does anyone have concrete ideas to support and attract URM students?
The first thing to ask yourself as you’re coming up with a plan is why you are actually trying to accomplish this. If it’s just because “it’s the right thing to do,” it might require some deeper reflection. Perhaps it will be helpful to review the evidence that diverse teams will make your department stronger, that they will increase your innovation and creativity, and that you will provide better care to your patients. This evidence can help engage a wider team to help you achieve your laudable goals.
Think about the culture and the ethos of your department and ensure that as you are recruiting and attracting a diverse set of candidates, that they’re going to thrive there. What’s the plan after you get them in the door? Are they going to struggle for four years? Data exist showing that Black house officers are dismissed at a significantly higher rate than their white counterparts from residency.
That may indicate something is broken in the residency and training system. So what is that? We have to look critically at how we run our programs — how we educate, how our policies and procedures are placed and how they’re enforced, and then what resources we use to support trainees.
How do we mentor you? How do we sponsor you? How do we connect you with resources that are going to be helpful as you’re growing your career? For example, I spend significant amounts of time mentoring medical students as they navigate the “applying to residency” process. Through this, I get to know them pretty well — their professional and personal goals, relative strengths and weaknesses, etc. I ask them to spend time reflecting on their own journey thus far, and visioncast what the future may look like. I believe this allows them to truly find programs that align with their goals, increasing the likelihood of success in residency and beyond.
What do you think about standardized questions being used by interviewers to help reduce bias in the process of selecting medical students and residents?
Having standard questions is incredibly helpful because it decreases, but does not eliminate, bias. A standardized approach means you are not choosing a question because of the way someone looks or because of the way they might have made you feel. It also helps the recruitment team compare answers across candidates in a more equitable way.
Similarly, creating an interview committee that understands how to interview and understands their own biases is critical to reducing bias. They’ve gone through the process that we talked about — internal reflection of who they are and why they think the way they think. And they feel comfortable being vulnerable, discussing, and saying, “No, I didn’t have a great interview with this person, but this might be why. It might be me, not them.”
Having a dedicated, trained interview group elevates the entire process and, I think, decreases the bias. The more we can standardize the process for people coming through, the more we can ensure that our decisions are based on what the applicant did, not something that we were projecting on them.
Of course, this takes time and resources from our departments. This becomes another way to evaluate a department’s priorities. If we, as a department, say this is important — shouldn’t we be spending the time and the money to grow our culture and to elevate what we’re doing? And if that’s not happening, why not?
You touched on reliance of test scores as a problem and it definitely is. The Basic exam perpetuates this reliance since programs have to pick applicants who can pass that exam. How can we, as a specialty, move away from the Basic exam and the priority it forces programs to place on standardized test scores?
The key question regarding the BASIC exam is: ”Why?” Why are we using these scores? What is the goal of these standardized tests?
Are they competency-based? For example, Step One is going to pass/fail. So it’s truly going to be a competency test saying that there’s a minimum level of knowledge that one needs to demonstrate in a multiple choice format to demonstrate that one should continue in medical training.
But we need to determine what we’re seeking out: Is it patient outcomes? Is it an ability to lead in a team? Is it resiliency? We spend a lot of time talking about all these characteristics we want to see in trainees and physicians and leaders, but then we have this gate that may filter out people who would have all those other characteristics we’re talking about. However, perhaps they struggle with multiple choice tests, when much of medicine is not a multiple choice test.
How can we identify new ways to screen for these sought-after characteristics? Can we rely more on personal statements and letters of recommendation? We know that takes more time and more resources than filtering out applicants based on test scores — but, again, it goes back to what you value and invest in as a department. It’s a difficult topic that deserves more conversation.
I’m a rising M4 pursuing anesthesiology. What are some ways that students can learn about/assess the diversity and inclusion efforts of residency programs during the application process?
The virtual environment has been both fantastic and really hard. But one thing that’s been great about it is that learners have more access than ever before to contact faculty members. They can easily set up a videoconference because it’s just normal now.
And so I think you need to ask programs the questions directly: What are you doing? What’s your mission statement? What are the concrete actions that you’ve taken and what are the results that you’ve seen? Who’s leading your department? What events are you sponsoring? What’s your curriculum for your residents, faculty, and staff?
Ask the residents questions because they will be the best resource to help you understand what it’s really like. Do you feel supported? Do you feel valued?
It can feel uncomfortable to ask these questions, but it’s one of the most important things you can do. Many programs have a website now that talks about their diversity efforts, but you have to dig deeper to understand the culture of the program.
With the significant impact of letters of recommendations on the residency application, what advice do you have for underrepresented students to really shine on an away rotation?
The way you shine as a medical student is to show up early, stay late, and let your natural curiosity be on display. It’s remarkably difficult to go to another institution and feel like you’re under the microscope for four weeks — it can feel like an extended interview!
But remember that you won’t be expected to know everything. What we’re really looking for is that you’re excited, that you’re curious, that you are patient-focused, that you are part of the team. Those are the things that really matter.
It’s also important for you to be yourself when you’re there. Don’t be who you think the program is desiring — be yourself! All programs and institutions have their own “feel.” You will find your place — the right fit for you, where the culture and mission are aligned with your personal values.
While that’s great advice for everyone, it is especially important for underrepresented students. We know within medicine that the expectations can be different at times for underrepresented or marginalized groups, where they’re trying to fit into the mean. But if they do not like the authentic you, that is not the right place for you. This is a time to think about where you want to go and why you want to go there: What do you know about their culture? Is it in line with your values or not?
So be yourself — but be your best self. We all have those times when we’re tired and we could do the extra work, but we’d rather not. That is when we all need to take that next step and go the extra mile. This is your unique opportunity to shine.
In terms of diversifying academia, are there initiatives to reform promotion beyond research production? Contribution to the field of medicine/anesthesiology goes beyond research: community involvement (and pertinent change in the surrounding community matters and often goes hand-in-hand with research), teaching the next generation of anesthesiologists, developing new anesthesia tools/technology, etc. Are these being considered in promotion in the university setting?
Many institutions and universities are moving toward assigning value and credit to activities and work that have traditionally not been rewarded.
If the people who are promoted at a higher rate seem to fall into a certain phenotype, we have to ask what it is about our process that makes one group more likely to reach professor. Part of that difference goes all the way back to kindergarten and the resources that were available — there are gates the entire way.
But looking specifically at the promotion process: Does it reflect the product you’re starting with? If 10 percent of our junior faculty are from underrepresented groups, is that true of our senior faculty as well? If not, what are we doing as an institution that is not creating conditions for success or promoting in an equitable way? How we recognize diverse contributions — and how we recognize those who devote their career to promoting diversity — are important topics for consideration.
We also have to think about what accompanies promotion and why that’s important. Is promotion useful to becoming a senior leader? Since this is typically the case, enhancing promotion processes will be critical for diversifying senior leadership.