Cancer Topics - Increasing Diversity in Oncology Practices (Part 2)

"Have you ever struggled to remember or pronounce a colleague’s foreign name? In part two of this ASCO Education Podcast episode, host Todd Pickard (MD Anderson Cancer Center in Houston, Texas) continues the conversation on creating more inclusive oncology practices with medical oncologist Dr. Timothy Gilligan and clinical psychologists Dr. Lauren Wadsworth and Dr. Stephanie Pinder-Amaker. They explore identity-related aggressions in the workplace and tips for practicing to recognize and address them.

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TRANSCRIPT

Todd Pickard: Hello, my name is Todd Pickard. I'm a PA specializing in genitourinary cancers at MD Anderson Cancer Center in Houston, Texas.

This is the second half of our Cancer Topics conversation on increasing diversity in Oncology, with Clinical Psychologists, Dr. Lauren Wadsworth and Dr. Stephanie Pinder-Amaker, and Medical Oncologist, Dr. Timothy Gilligan.

In part one, we discussed workforce diversity in Medicine in the various prejudices, biases, and microaggressions that can take place in the workplace. We also explored real-world examples of bias in healthcare from Dr. Wadsworth and Dr. Pinder-Amaker's book, Did That Just Happen?!

Today, we're going to continue our conversation by exploring cultural-sensitivity tips for individual healthcare providers and practices. Welcome, everybody.

You know, we could have a great conversation about this for hours, I'm really enjoying this conversation, but I do want to get back to the book. Dr. Wadsworth, are there any anecdotes from the book that you would like to share with us that might illustrate some of the things that we've been discussing so far?

Dr. Lauren Wadsworth: Yes, we would love to. So, each chapter of the book starts with a real story. So, a vignette that's been de-identified of an identity-related aggression happening in the workplace, or some other type of, Did That Just Happen?! moment, as we like to call them. And then after the vignette, we break down what was problematic about that dynamic and what to do about it, both in the moment how to make a repair, and how to change your workplace culture to prevent this kind of thing from happening again, or to reduce the incident. Our hope was that if we started with vignettes, to a point that you made, Todd, earlier, we might be able to welcome folks in that are maybe on the fence about reading a book like this, and instead of bringing up defensiveness, trigger empathy. So by telling a real story, our hope is that folks will have empathy, come up, and then curiosity about how they might be able to do things differently.

Dr. Stephanie Pinder-Amaker: The title of the chapter is, “What's in A Name?”, and this is Dr. Daisy's story.

"Adaeze Adebayo-Opeyemi arrived as the highly recruited young doctor to a tier-one academic medical center on the West Coast. Like many young professionals of color, she had grown accustomed to being one of the few or the only physician of color in her class. Throughout her medical training, she'd rarely seen her identities reflected among the professional staff but knew that she could readily find people who looked and perhaps sounded like her among the hospital's food services and environmental services staff. Sometimes she retreated to those spaces for respite."

"Dr. Adebayo-Opeyemi knew exactly how to respond to her patients' surprise when she introduced herself as their doctor. She knew to pause and wait for them while they awkwardly set aside the meal-request cards they had hurriedly tried to complete when seeing her enter the room. She knew to take a deep breath when they scanned the room for some external confirmation of her credentials - perhaps a nod from an approving white hospital staff member - if she was headed toward their medical chart. Along with reading a chest X-ray and delivering devastating lab results, she had honed these skills in medical school. Still, she was unprepared for the series of identity-related aggressions (IRAs) she faced in this prestigious setting. IRAs, a term we coined to remove the "micro" from microaggressions, would come in all forms - from patients, fellow peers, and supervisors."

"First, due to a misspelling of her last name in the hospital system, Dr. Adebayo-Opeyemi was not able to begin the year with the other incoming physicians. Until the error could be rectified, she was locked out of the medical records she would need in order to care for her patients and complete their orders. Two weeks later, when she was finally permitted to start, her supervisors were frustrated that she was "just learning" to access the medical records and complained to the training director that she was not of the "same caliber" as the other residents. In addition, she found that some of her colleagues struggled mightily to pronounce her name. Others barely attempted. Dr. Adebayo-Opeyemi, ever mindful of how awkward these interactions could be for her colleagues and patients alike, quickly granted everyone permission to "just call me Dr. Daisy!" Unbeknownst to her colleagues, however, in Nigerian culture, an individual's surname is a source of great pride and significance. "Dr. Daisy's" father, Onye Opeyemi, had been a chief. Dr. Adaeze Adebayo-Opeyemi is a descendant of royalty. Her gesture of collegiality in the context of a seemingly simple clerical error had not only undermined a critical professional transition, but it had also begun to erode her sense of self and reputation in the workplace."

Dr. Lauren Wadsworth: Why this is problematic: Dr. Adebayo-Opeyemi's experience illustrates how institutions that are ill-equipped and under-practiced in working with individuals with a range of ethnic backgrounds, and other rising identities can erect significant barriers to employee success. It's easy to see how enduring an environment like this could lead anyone with an underrepresented identity to shut down, lower expectations, and bring only part of themselves to the work. Only a culturally humble and responsive setting would recognize that when Dr. Adebayo-Opeyemi acquiesced, asking the staff to "just call me Dr. Daisy!", and staff complied, they became co-conspirators in the erasure of her ethnic identity. This is an extremely common occurrence where individuals are urged to take on an ethnocentric name, to make things easier for the privileged group.

Todd Pickard: You know, this vignette really resonates with me because I work with many individuals, and I've worked in ASCO with many individuals who have very different names than my European name. Even though people might want to say, “Picard” versus “Pickard”, they're both pretty close. And I find it interesting how many folks will take on an "American name." They may be Asian and they'll say, "Call me Steve," because people can't say their real name.” Or they'll have a very long last name which is very common from where they're from, and they'll say, “Just call me Dr. O." So, I can only imagine how that resonates with folks who experience this.

So, what can we do about this? You know, on an individual level, how can we learn to recognize and ultimately overcome biases and assumptions? I'd like to ask all of you, but I'll start with Dr. Gilligan to bring him back into the conversation, and then we'll each take a turn.

Dr. Timothy Gilligan: Well, I want to start with the brief observation. One of the things I took out of that story, which I think is really central to this whole conversation is, "Whose identity is centered?" And I have many colleagues who don't have European names who adopted European names. My sister-in-law is a Urologist at Harvard, and her name is Golbarg. But in training, she went by "Cathy." "Cathy" is not a name from her family or her background, but it was to make it easier for the white European mainstream American culture. And I think one of the things our trainees encounter when they enter the training environment is that very certain identities are centered, and other identities are not. And for underrepresented minorities and other people with marginalized identities, typically their experience is not centered, and they notice whose identity it is.

And when you have a privileged identity, and I hold multiple privileged identities, you get used to being in a world that caters to you, and I think we have to become aware of this. And this issue of learning people's names is not trivial. When we survey our medical students about their complaints, one of the top two is students of color getting called the wrong name, because they get mixed up, because residents or the faculty don't distinguish different black students from each other or different Asian students from each other.

Todd Pickard: It's a great observation. One of the easiest places to start to have awareness and to be open to learning is to take the time and effort to learn somebody's name, and to recognize people as individuals because we all are. I, myself, have difficulty with names that are not Eurocentric or Czechoslovakian, because I'm also am Czechoslovakian, and also am French. So, anything outside of my comfort zone is difficult for me, but I recognize it, because I respect and value my colleagues. And I know if somebody called me Fred all the time, I'd be like, "But my name's Todd." So, this is something that's important, and I think you bring a great point. I mean, that's a great place to start, but there's more, right?

So, Dr. Wadsworth, what else can one do to learn to recognize and ultimately overcome biases and assumptions?

Dr. Lauren Wadsworth: So, one of our favorite things in life and in the book, for Dr. Pinder-Amaker and I, is to come up with real-time practices that people can do. So, our experience is that so many books on diversity, equity, inclusion, really emphasize what you were just talking about, Todd - building awareness. And then they kind of stop there. You know, it's like focus on building awareness and then get better. And what we're finding is that people really want to do better, and are expressing that desire, but are really struggling to say things like the word "racism" in the workplace, or name “I think a microaggression just happened.” We were socialized not to do that, not to talk about race, but we think that practicing words, practicing language, practicing names, can be so helpful.

So, when it comes to names specifically, some practices that we recommend in the book, and that we've expanded on since are; one, asking someone if you can record their name when they share it with you the first time, so that you can practice it independently, maybe download the VLC app and play it on loop while you're driving into work one day, and that would probably be sufficient to learn it. We also have met with groups that whenever a new person joins, whether their name is Eurocentric or not, everyone in the group repeats their name four or five times as you go around the circle. So, I would introduce myself as Lauren, and everyone would say that four times, and same for anyone else.

You could also, say you are teaching a class, or you have a new resident coming in and you're going to have to take attendance, and you might have to say people's names for the first time before they introduce themselves, which is something that gives people a lot of anxiety. Many of the names that folks have are on YouTube, and you know, three-second clicks, you can look up common pronunciation and do some of that practice on your own independently. You might be wrong about how they're pronouncing it, but you're probably going to be a lot closer than just making something up in your own mind.

We can also practice things like using they/them pronouns in our groups by doing things like deciding that every staff meeting from now for the next three months, we're going to only use they/them pronoun to refer to everyone. So, whether it's a patient or a colleague, we know their gender identity, or we don't, we're just going to use they/them pronouns for everyone so that we can get better at integrating that as something that we do in our everyday language, so that when a patient comes in that uses they/them pronouns, we are able to just do it automatically versus stumbling and trying to learn it for the first time in the presence of someone that could be hurt by our never having practiced it before.

Todd Pickard: That's really an interesting point about practicing. You know, practice does make perfect, right? And you learn from the mistakes along the way.

So, Dr. Pinder-Amaker, what other advice would you have?

Dr. Stephanie Pinder-Amaker: One of the things that we really emphasize in the book and in working with organizations directly is giving people both permission and the opportunity to practice naming the -ism. As we talked about earlier today, for reasons that go directly back to some of the research cited at the outset of this podcast, as society, we have become much more comfortable, for example, with naming sexism, when it occurs in the workplace, right? We know how to use those words. It's not uncommon to hear someone maybe call someone in for a sexist remark, or to call someone out, as the case may be, for having made a sexist remark. But what we're finding is that as people are increasing their sense of urgency and desire to get some of this right, that it's really important to give people permission to name additional -isms, to name racism when they see it. And to hear themselves saying the words, and to hear each other saying the words, because as we talked about earlier, historically, we've really been taught not to say these words in the workplace.

And we really struggle with calling a thing, a thing. To the point made earlier about the importance of validation, that's a big part of validation. Being able to say, "I hear that that happened, and you know what, that really sounds like it stems from a place of racism and it's not okay." That's what validation sounds like. And it's important to give people opportunity to practice saying those words.

Todd Pickard: This is such a fascinating conversation; I'm really enjoying it. I know that we are getting close to our time, so I'll start to wrap us up with a final question for the three of you.

Dr. Gilligan, I'd like to start with you about what tools and strategies and medical practices are you aware of, or that you have used to increase diversity or at least to do diversity awareness and reduction of microaggressions or biases within your own practice.

Dr. Timothy Gilligan: So, my approach, I think is very similar to what Dr. Wadsworth and Dr. Pinder-Amaker are talking about in terms of trying to develop some muscle memory, that this isn't a question of transmitting cognitive knowledge, and if someone just understands it, they'll stop doing it. They need opportunities to practice.

Recognizing it, and then also to practice responding to it when they see it. Whether it happens to you or whether you witness it happening, people need to feel some confidence. Because I think just like oncologists are notorious for talking about death with patients who are terminally ill, even though patients with cancer naturally think about death because people associate cancer with death, I think we have the similar version to talking about racism, as she said. And yet it's guaranteed that the other person's already thinking about it, you're not introducing a new topic. But people need comfort bringing this stuff up and knowing what are some skillful things to say.

I mean, I have a colleague who uses the phrase, "I'm curious why you're comfortable saying this to me," which I thought was a wonderfully gentle way of pushing back when a microaggression was committed. So, we could teach people phrases that work for them. And what works for me may be different than what works for you, but people need a chance to build on that.

And I think the other thing that we're trying to do is, honestly, there’s huge disparities in care. There's abundant evidence that black patients are treated differently than white patients, and Latino patients are treated differently than white patients, and women are treated differently than men. There's actually a meta-analysis in a major journal showing that if you're a woman with an acute coronary syndrome, you're 5% less likely to die if you have a woman taking care of you than a man, because men don't follow guidelines when they take care of women with acute coronary syndromes. And so, just getting the news out there that bias is real, is measurable, is well documented. So, the question isn't whether or not it's happening, the question is, how do we reduce it? And the skills practice I think is really fundamental to them, in addition to the awareness.

 

 

Todd Pickard: You know, one of the things we've done in my practice is, we have cultural-sensitive care. So, when patients with different cultures request respectfully, you know, “I want a woman provider because I'm a woman,” and that makes complete sense, it's very easy to accommodate those. But when we find overt aggressions, "I don't want to see a black person. I don't want to see an Asian person." We frame it in terms of safety, and quality, and competency. And so, we change the conversation around the concern and we frame it in, "Well, this is our healthcare provider who is best qualified to give you this safe, quality care." And so, this is how we make sure that you get the care that you need. That generally has worked for us, not always, of course, but I think that's a good way to remind folks that, yes, you can provide cultural-sensitive care, but when there's overt aggression or microaggression, you have to have a strategy to address that with patients, or even with other coworkers.

So, Dr. Pinder-Amaker, what are some other advice that you would give for practices to do better in this arena?

Dr. Stephanie Pinder-Amaker: I think another bit of advice that we often recommend and find helpful, at least we get feedback that people find it helpful, is to decide together as organizations, as groups, as practices, how you want to receive feedback around some of these issues. Really doing that proactively acknowledges that we are going to mess up, and can help free people up from the state that we often experience of paralysis, that we're so afraid that we're going to make mistakes, that we do nothing, and that is not acceptable, that is not going to get us where we need to be.

And so, it's sort of, again, about giving permission to folks to say, "Yeah, we're going to get better at doing this, and it's not going to be perfect, but we are perfectly committed to doing this. And one way that we're going to demonstrate that is to think together as a group, as a practice, how we want to receive feedback when we do mess up, when we make an identity-related aggression, or practice racist behavior, or oppressive sexist behavior.” How do you want that feedback? So, it just gets people sort of comfortable and thinking about not being comfortable with making mistakes, but comfortable with the inevitability that they're going to make a mistake. But as an organization, as a practice, we're going to be able to move through this so that we can keep getting better.

Todd Pickard: Good advice. Dr. Wadsworth, any final thoughts or recommendations, or things to bring to our listeners' awareness?

Dr. Lauren Wadsworth: Sure. I think I'm going to build on Dr. Gilligan and Dr. Pinder-Amaker here and say that it can be helpful to build very explicit step-by-step guidelines for what to do when we've messed up. This is an awkward, uncomfortable, unpracticed topic for, I think, everyone. It's uncomfortable for folks making mistakes, it's uncomfortable for folks who are being harmed, and it's uncomfortable to then talk across identities about these things. So, one example of something that people can do, building on talking about how they want to receive feedback is to make a series of community guidelines for exactly what we want to strive to do when we've messed up.

So, for example, on the table in our meeting room, we have, when you've messed up when you've received feedback that you've engaged in an IRA: Step One: Take a deep breath, you know, notice any defensiveness coming in. Two, say ‘thank you’; express gratitude for people taking the great risk, and great labor, an emotional labor of educating you in a moment when you've caused harm. Three, recognize and name where your IRA came from. So, “That statement I just said came from racism.” You don't have to say, "I'm a racist person." We're naming the societal training that we've been given by saying, "That statement came from racism." And then, talk about, express commitment to exploring why this came up, why you said that racist thing, and a commitment to doing less of it and how you're going to work on that. So, “I'm going to do some reading on other microaggressions that come up around race by quick Google search and try to catch these in advance” and say “sorry” briefly. So, not going on and on, "Will you ever forgive me?” or, “I'm so embarrassed, I feel terrible," and then making yourself the emotional focus, taking the stage, but making a quick succinct apology.

So, by having something that's concrete like that, that's written out, giving the group permission to literally pause and pick up the sheet helps people start to do something that's really uncomfortable with a lot more structured framework, giving us permission to use supports and structures to start practicing this work together.

Todd Pickard: I really appreciate that concrete example. And in my mind, I said, "Wow, I want to use this anytime I mess up." It just gives you a framework to acknowledge it, but not to suck all the oxygen out of the room and take the stage. It's just to say, "Here it is." Well, you know, this has been a wonderful conversation. I'm so appreciative to all of you.

So, thank you so much, Dr. Pinder-Amaker, Dr. Wadsworth, and Dr. Gilligan, for all of your candid and insightful conversations today about the lack of diversity in the workforce, and microaggressions, and implicit biases. I'm sure our listeners are going to appreciate the personal anecdotes and these practical communication tips that you have all shared today on how we can maintain awareness and work together to sustain a diverse workforce. So, thank you all very much.

Dr. Lauren Wadsworth: Thank you for having us.

Todd Pickard: Thank you all so much to all of our listeners. We appreciate you tuning into this episode of the ASCO Education Podcast.

 

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