And now I would like to introduce our speaker, Dr Chase T M Anderson, uh who just goes by. Chase is currently a child and adolescent psychiatrist at U CS F. He graduated from adult psychiatry residency at the Massachusetts General Hospital and mclean Hospital and did child and adolescent psychiatry fellowship at U CS F. He completed his undergraduate education in Chemistry at the Massachusetts Institute of Technology and received his master's in biological engineering at M I T as well. He's a graduate of the Northwestern Feinberg School of Medicine. His writing has appeared in Newsweek W B U R slash N Pr Scientific American that news, the New England Journal of Medicine and other news and journal outlets. In his free time. He enjoys going for long walks, listening to K pop, reading fantasy books, playing soccer, writing, planning dinners with friends and dreaming of how we can better the world together. And these hobbies make me want to find better hobbies. Um And lastly, I will also say I forgot to mention for any questions that come up. I'll try to save some time at the end. So please use the Q and A function in your Zoom tool bar and we will try to get to as many as we can at the end with Doctor Anderson. So I'll hand it off to you Chase. Thank you. Um Thank you so much for that introduction and it's really lovely to be here with all of you. Um So what we are going to talk about today is minority stress. Just a heads up. I'm very open about my own mental health and I live with depression and anxiety. Um So if there's anything during the talk that is triggering or that is like worrisome to you, then just like, please know that like this is a safe space to like take the space that you need to. So have your cameras on off or whatever you need to do and feel free to like take a moment to yourself too. Um We're just gonna dive into some of those things in order to fully understand what like minority stress does to people. Um And no questions for me are off the table, feel free to ask anything about my mental health or like how I navigated things too. Um And I'm just really happy to be with all of you. So what we will be doing today is minority stress in the medical professional, how minority stress affects mental health. So this is actually a modified presentation that I gave with one of my colleagues back when I was in residency. His name is Mark Busan and he's at Stanford now. Um And so it was part of a Q I project that we did. And so that's the only time I will say that Q I projects are very useful that you do during residency because sometimes it can launch your career a little bit. And we're gonna keep going from there in terms of disclosures. I have no disclosures. I am not paid millions by companies. I wish I was but I am not. So we there are no disclosures in terms of an overview. Part one will be a personal vignette. So just a little bit of background and narrative to bring you into the story. Part two will be what is minority stress. So some definitions to bring everybody onto the same page. Part three is minority stress in America and in health care. So some statistics to keep in the back of your minds and things to think about when you work with patients, especially pediatric patients. Part four will be anecdotes of minority stress. So these are things that mark and I gathered from colleagues in the hospital as well, the staff members as well as other patients. Part five is how do we help and how do we grow? I'm always um somebody who's very perpetual optimist and hopeful. So how do we help people get better? And then part six will be how can minor ize people protect themselves. So some specific tips and tricks. Part seven, will be future directions of thought. Part eight is a personal vignette revisited to wrap up the story that we begin with. And then part nine is A Q and A in terms of learning objectives. At the end of this presentation, learners will integrate into their practice, the ability to specify at least three ways in which minority stress affects mental health. Two is assess how minority stress can affect minor ized trainees and faculty in the medical system. And then three is identify at least three ways in which we can make academic environment safer for minor individuals. So let's start with the personal vignette. My life changed when I came out at age 12 until then overall, I'd lived this idyllic little life where I was educationally and economically privileged in ways I didn't even know at the time, I hadn't heard the N word yet. I knew the word. The world was hard for gay people from newspapers, but I didn't fully grasp how things were about to change through the next years into high school. It was called the N word homophobic slurs. And I went through bullying because of facets of my identity even though I was one of the top students, even though from the outside, many people thought I lived this perfect little life, even though I made it look good. People didn't know that at my high smile hid so much. I didn't know what to call it at the time. But I began to develop depression and anxiety. I feared going to school even when I loved learning in high school because of discrimination I faced, I had one suicide attempt. No one knew I wasn't hospitalized. Then I entered college at M I T and my life changed for the better. Not at first though within the first few weeks, I was rejected from a fraternity because I was open about being gay, had to meet with M I T Faculty about it and subsequently failed all my first exams because I developed panic attacks for the first time. I was no longer a stellar student. I was sure I was going to fail out. This led to my second suicide attempt again. No one knew at the time I thought I was going to end up dead. Yeah, something different happened. The friends I'd already made at M I T validated my experiences of discrimination, shared their experiences with discrimination and mental illness, how and how they dreamed about changing the world. They bonded more tightly with me and we learned how to support each other. We saw each other as more than the characteristics often used to define us and shattered those stereotypes. We became a family where we spoke about topics of diversity regularly and shared our lives with each other because of them. I made it my purpose to help others not experience the same issues I had, I got to see what it meant. To truly live. It wasn't perfect and there were instances of discrimination, but it became more rare as time continued. And there was always someone besides myself who spoke up against such instances, they saved my life. They helped me soar for the first time as I embraced my identity and we celebrate each other's identities because of our friendship without meds or therapy. I entered what was later called the Golden Years right before grad school at M I T A two year period where I didn't have a single depressive symptom or any suicidality. I thought my depression was gone forever and I was cured. I left M I T with a certainty that America was ready for a shy yet confident black gay, introverted guy nicknamed Dream and a unicorn phoenix by his friends medical school. However, was about to disillusion me and bring back the one thing I thought was cured forever. I became class president in the first few weeks and things became a slow descent into hell. I was told by a classmate that I won class president because I'm black and gay. I heard how I talked about being minor. Too much. I started to get shut out and shunned even from events I helped plan with classmates. Six months in my depression, anxiety and suicidality had returned every day, became about social navigation, balancing class president, finding allies, including our vice dean, certain attendings and deans educating people constantly about the discrimination they were enacting, taking on certain deans who had discriminatory behaviors, making changes with others, handling school work and planning my escape from medical school. All the while my identity fractured, I began to fail exams. I cried alone at night and woke up screaming from nightmares. I couldn't even tell my friends from Boston what was happening because of the shame I felt because of all of that. I started medications and therapy for the first time. Yet, even with medications, therapy and abundance of friends in medical school and alliances built that didn't stop the flood of constant discrimination that continued to break me. I failed four shelf exams in a row. I had never felt and been made to feel more alone. This led to one night in third year where I had plans and intent to suicide. After that night, there were several breakthroughs including being more open with my friends from Boston and my family in Seattle about how bad medical school was. And I honored my surgery shelf and taught myself further tools to more fully face down discrimination. But I felt like a shell, the person who once dreamed of more. Although my psychiatrist therapist and I agreed I entered clinical remission in my fourth year, my symptoms flared whenever I experienced discrimination. I couldn't figure out why my depression didn't fit the classic criteria we used in psychiatry. But that clinical remission was enough to hold me studying. I then matched back in Boston at a university where the program director said during interviews that she hadn't heard about issues about being black. But if there were issues, I'd be supported. I raced back to my friends in Boston hoping to feel truly safe again in residency. I saw the descent into chaos coming a bit better this time for the my psychiatry rotations for the first three months, I was told I was above where I needed to be. I thought I had finally found safety even when an attending who was also minor warned me that appearing to be confident and competent as a black gay male would lead to discrimination and backlash. I thought that couldn't be true. Then on my internal medicine rotation, I had an attendant who kept pimping me in front of colleagues in a way that caused my panic attacks to flare. When I told her this, her pimping worsened. I heard how she had done the same to other trainees in the hospital. I was being called the name of the only other black psychiatry resident who looked nothing like me. Asked if I was there as transport. My knowledge and the knowledge of other minor people was constantly questioned and I was disparaged by some patients and staff and saw the same happen to colleagues. One week later, found me standing at the sink in the hospital bathroom, crying before rounds, suicidal, having for to force myself to go to work and not run away on her evaluation. The attendant said I was unprofessional, was worried about my being a danger to patients and that my knowledge was far below my peers. Although other evaluations said I was above where I needed to be and praised my professionalism. My program directors labeled me as unprofessional, rated my knowledge and professionalism below my peers. And I was ignored when I told the and I was told the problem, I, I was the problem when I told one of them about what was happening inside of the hospital. I had to do a pseudo remediation with the internal medicine chief resident mornings after working overnight where senior residents said I excelled, faculty had supposedly secret meetings about my not wearing a tie. I'd rarely felt more stupid or embarrassed or that I was the problem. My suicidality worsened in frequency and intensity because of so many lived experiences. However, this time, I knew what to do to survive with my residency class. We strategize how to handle program leadership and make changes. Then we went to war with our program when we deserve peace in a safe training environment. I set aside the guy who wanted to simply date another guy and have a calm life in order to mentor others push where I could with faculty and support my colleagues. I led with vulnerability and used that as power when I spoke up constantly when I wanted to simply sit in quiet peace and dream upon the stars of my old friends. This time around, I was open with my old friends from college and family in real time about what was happening even as I had less time with them because I didn't have the energy. My colleagues set aside many of their dreams. And as we spoke up constantly and consistently, I restarted my antidepressant, which I've been able to come off of after leaving medical school. I also started therapy again. This time, I wasn't just scared. I was going to lose my, lose my life. I was constantly terrified as I watched my spirit fade. One year later, soon after one morning where my suicidal thoughts became more intense with intent. And then I went on to have an attendant tell me my work was excellent. That day, the same program director who hadn't listened when I told her how bad things were and was crying as she apologized to me for how she hadn't listened, how she had put me in a horrible position. And for how the program had hurt myself and others. She and I then got to work every week. We'd meet to discuss aspects of her identity. The program, certain instances of discrimination I or other classmates had experienced. This was all on top of working to be the model minor physician that didn't stop the depression. It didn't stop the daily discrimination I saw or experienced, but it did have helped to have a leader who validated myself and others and who worked to better things. At the same time, I was planning my escape from the program. I began to speak out about experiences under a pseudonym on Twitter because I wanted other people to not feel so alone. When the cop program director who is now an ally announced she was going to another program that solidified my decision to fast track during interviews. I had better questions this time around because for minor ized applicants, it's not simply about, oh, this is a great program. It is about where will I be safe? Where will I experience the least discrimination? Faculty at U CS F were the most honest I matched at U CS F. Then George Floyd was murdered and people were who had enacted discriminatory behaviors were rushing to apologize, invaded my space when I wanted to be left alone. Our program even said how they had hurt people but never specifically apologized to anyone. And discrimination continued I forgave because I saw it as people having blind spots and enacting learned behaviors from society. But that didn't stop the knowledge that their rush to assuage their guilt and their delayed apologies, didn't heal my shattered heart or give me back the lost time, dreams, peace or sense of self. So I geared up to leave with plans to leave academia. Fellowship was more of the same began saying goodbye to my oldest friends and newer friends and mentors wishing that the program had been safe enough for me to stay in Boston with those who I had promised to be together forever with. So what does that all have to do with minority stress? The typical definition is the process through which stigma directed towards sexual minorities influences health outcomes. This term came about in 2003. And Doctor Meyer or Doctor Elon Meyer had actually come up with this term earlier and used it from other people who had mentioned it, but because it didn't gain traction, he actually wrote about it again in 2003 in order to like propel it forward into the public conscious. However, the definition is much broader than that. So out of that comes the minority stress theory. So this is the more elegant explanation, individuals from oppressed social groups experience excess stress and negative life events because of their nondominant status or statuses, which can lead to exacerbate mental health problems. These effects are unique, socio, culturally based and long lasting, which means they're additive. The way I like to think about it or describe it to kids that I work with is think about getting a paper cut. You get one paper cut in the beginning of the day and you're like, ok, that'll heal it stings. It's annoying, but I can handle it. Now imagine getting 1000 paper cuts a day eventually, you're not sure where you're going to get those paper cuts from. And then you're bleeding all over the place and then you don't know how to put yourself back together again. The other way I like to think about it is I like to watch Sailor Moon, the original Japanese version because it's really good. And she has this thing called the silver crystal which combines like and contains all of her energy and power. Think of that as representing someone's sense of self. If you get one crack in like the beginning of the day, like being called the N word, then you get one crack and you can heal it, you can patch it up, maybe it'll seal by itself. However, if you get multiple cracks throughout the day, then eventually your shine begins to shatter and then your sense of self spreads all over the place and you don't know how to put yourself back together. That's another way to think about it. Along with this comes institutional discrimination. So these are disparities that systematically favor certain groups. This includes housing. So back in the day, there was this thing called red lining in Chicago. So African American people's homes were appraised at lower value that compared to white people's homes. And African American people were only allowed to live in certain areas that actually still plays out. If you think about like how our economics and how like our housing works inside of S F and like other places as well. This also includes in schooling, employment, health and justice. So how does minority stress play out in America and in health care? In terms of some racial statistics, a study by psychologist Randy T Lee looked at major lifetime discrimination. So this included being physically threatened, being physically assaulted, being called like slurs, things of that nature. So 48.9% of African Americans said that they had experienced major lifetime discrimination that's versus 30.9% of white people. The reason it's so high for white people is because women are included in that category as well in terms of day to day discrimination. 44.4% of white people said they had never experienced data day discrimination. Only 8.8% of African Americans were able to say the same thing in terms of pay discrepancies. They looked at people who came in at the same educational level and the same like we're doing the same work, we're doing the same like things at work. And so they saw that there were actually pay discrepancies as well as people being promoted disproportionately. So 57% of African Americans versus 32% of Hispanic Americans versus 31% of Native Americans versus 25% of Asian Americans experience. These pay discrepancies that I talked about earlier. That's versus 13% of white people saying the same, the slide is a little bit busy, but I wanna draw your eye to the yes, regularly column on the right side. So this is yes, regularly experiencing discrimination. If you look down the column, every racially minor group will experience discrimination at a higher rate than white people. So for white people, it's 3.8% for black people, it's 11.23% for Asian Americans, it's 10.85% and so on from there in terms of LGBT Q plus people. So they actually do this study by annually where they look at different high schools across the country and then gather data about discrimination and like how safe they feel. So when some of the statistics are a little bit different for heterosexual people, just remember that the reason it's different is because they were looking at different high schools for you identifying as LGBT Q plus all sexually minors, adolescents reported higher rates of violence victimization. This included feeling unsafe, being forced to have sexual intercourse, being threatened with a weapon being bullied at school or online in terms of gay males versus straight males. Instead, in terms of bullying, gay males said that they had bullying at school at 27.7% versus 14.6% for heterosexual people. That's about double the rate. Lesbians also reported higher use of cigarettes and marijuana and that they the prevalence of cocaine, heroin, methamphetamines, ecstasy and inhance were higher in all sexual minority groups. So just when somebody comes to you and they're using substances and they're LGBT Q plus or minor thinking about where is that substance use coming from? What are they coping with that they weren't able to cope with because of societal structures. This also sadly plays out in the term in the prevalence of suicide attempts. So this is where the statistics are a little different on the right that I told you about for lesbians and gay people. The prevalence of suicide attempts was 24.3% versus 13.1% for heterosexual people, for bisexual people. It's 28.3% versus 23.2% for people who said that they were unsure about their sexuality. The statistics actually reverse and so it's 12.4% versus 14.9%. The reason that they think this is reversed is because people who said that they were unsure might not have displayed stereotypical traits about being LGBT Q plus, but then didn't expose them to traumatic experiences or bullying. Terms of drawbacks of the study. They are actually high dropout rates and they actually think this is an underestimation. So I think when you think about it, a lot of LGBT Q plus people are known for forming their identities earlier and they are actually studies about this. So that actually exposes you to more discrimination earlier. So some kids don't even make it to high school because they drop out before then because of bullying. And sadly, since the 2016 election, this has only gotten worse. The FBI keeps track of hate crimes that are reported. And so what they've noted is that for racially minority people, LGBT Q plus people, anybody who is minor even religiously, we are actually seeing a higher rates of like discrimination happening as time goes on. So who we think about and who we pick about, pick for leadership in our country is very important and portends like there's a ripple effect that happens as well. So in terms of Asian American sexual minorities, uh the studies that were done previously looked at saw poor mental health, but those were in predominantly white LGBT Q plus samples. So research demonstrated that external racial stressors among Asian American sexually minors, individuals result in greater psychological distress. A study done at the University of Tennessee noted that Asian American LGBT Q plus per persons experience rejection, prejudice and discrimination from the overall LGBT Q plus community. There is a huge amount of racism inside of the LGBT Q plus community. So if somebody comes to you and says that they are LGBT Q plus asking about their community and their support is very important because if they say like I have gay friends, that doesn't mean that they aren't experiencing discrimination inside of the gay community as well. So always thinking about how does somebody's intersecting identities play out inside of their different communities. They also noted in increased inter inter internalized heterosexual. So that's internalized homophobia because of violating traditional Asian values such as harmony and complementarity. So thinking about how different cultures and different parts of somebody clash with each other or can be protective among 314 LGBT Q plus people of color studied 58 of whom were Asian American. They saw higher rates of depression, perceived stress and need for acceptance. They also saw ethno sexual mythology. So this is fetishizing by a different name, cannot tell you the amount of times when I lived in Boston Chicago, that when I was on grinder, because like, what else was I doing besides studying and being on grinder, um there are actually people would open their messages to me with like I love your black skin or show me that black like sexual organ. So people reduce you to your skin color without actually thinking about you as a person. They also saw competing identities. So what I was talking about with different cultures and different aspects of yourself that can clash and they actually saw a lot of resilience. So people were able, who were Asian American sexual minorities were able to use different parts of their identity in order to protect themselves against like discrimination. So along with that comes the need to talk about intersectionality. So this is the interconnected nature of social categorization such as race, class and gender which create overlapping and interdependent systems of discrimination and disadvantage or advantages. I sit before you and I'm African American and gay because I'm African American. I, I get really nervous around police people just because of what's happened in America with shooting of unarmed people who are African American. And so what I do when I walk past them is I actually will like change how I walk and I change my voice inflection. So they will use like aspects of being gay in order to be protective around being African American. So just thinking about how like we come from a very deficits lens when we do like medicine and things like that and thinking about people's identities. So thinking about how those identities can actually be strength based things for them. Along with this comes the intersectionality paradox. So they saw that African American women with higher education levels actually had higher rates of depression than other people who are white. And they thought that like at higher education and higher socioeconomic standing would be protective for people. However, for minor people, it's not, it just exposes them to different rates of discrimination and different ways of discrimination that are usually more subversive. So always thinking about just because somebody is educationally or socioeconomically privileged if they are minority in a different way, thinking about how that impacts them still, even if they are advantaged in other ways. Along with this comes the multiple jeopardy perspective. It's also known as the multiple disadvantages approach and also known as the multiple hierarchy stratification. So this is assigning high and low status traits for people based on the different parts of their identities. So an example is an Asian American bisexual female in America would be assigned three low status hits and then somebody who is the reverse would be a white heterosexual male. So that's assumed to be the jackpot in America with three high status traits. However, there's a need to look at identity experience just because somebody is white heterosexual male does not mean that they were educationally privileged. It does not mean that they were socioeconomically privileged. So always taking a step back when we're working with patients and working with our colleagues to think about. Where did this person like what is their story? What is their narrative? Let's not reduce people just to the symptoms that we are taught to reduce them to. So what's missing from what I've talked about so far after an extensive re like search that mark and I did on PUBMED on Google. Yes, we looked at Wikipedia like everybody does it also plus one as well as research gate. So LGBT Q plus research often lumps all categories together instead of thinking about like Asian American and bisexual or like African American gay. A lot of research that's done will say like LGBT Q plus people and then we'll like kind of just go from there. So we need a little bit more granular view in terms of the research that we're doing. There was also a dearth of research on intersectionality that's changing as time goes on. Women are also minor ized when using this model. So thinking about women in academia, women in research centers, women in general, how often are women actually promoted compared to their male colleagues, even when they're doing the same amount of work? Also thinking about even your own university, how many women are in leadership? So there's also we need further racially minor ized groups and more like granular view on that level too. If you remember the slide that I showed earlier. So on the left, it just said like Asian American Black like things like that. So what you want to take a step back and think about is inside of being Asian American. There are a lot of other categories and other parts to somebody's culture and other identities. So thinking about how do we dig down a little bit so we can get better research as well and also elderly populations fit this group. So a lot of LGBT Q plus people who are elderly, even if they were out when they were younger, sometimes they'll go back in their clo the closet with their physician because they feel unsafe or have heard horror stories about how they'll be treated. This also happens when they go to skilled nursing facilities. So when you're sending somebody to a skilled nursing facility or like even foster care or other areas, thinking about how well are people who are minorities actually supported in those groups. So minority stress regarding patients, we're gonna talk about microaggressions first to bring everybody up to speed. Everybody probably has heard about microaggressions. But we're gonna dig in a little bit. Microaggressions are broadly defined as behaviors that ambiguously disempower racial minorities. There are actually three categories underneath that though. So microaggressions is an umbrella term and then there's terms underneath that. The first is micro assaults. So that's explicit acts of racism saying someone is a lesser worth. The next is micro insults. So saying you didn't earn your position or you got what you got from affirmative action instead of saying like even if you got what you like your position from affirmative action, we are counteracting the societal structures that have led to like his historically being disadvantaged. There's also micro invalidation saying we are all the same that takes away from recognizing that we are actually all different people. And we need to recognize that along with this comes health care, micro aggression. So these originate from aversive racism saying we aren't prejudiced, we don't have racist tendencies. If you are white and born into America, you we all have racist tendencies. So people who are white have racist tendencies because of the societal structures that they're born into and what they are taught from an early age. Other people who are minor IZED also have biases. We have biases about height weight, like thing other things. So always taking a step back to recognize like, yes, we all have biases. We all have things that are going on inside of our heads that are automatic snap judgments. How do we recognize those and move past them and work with them along with this comes the term institutional betrayal. So this is basically normalization of bad behavior. The example is that if a medical student goes to their dean and says, I experience discriminatory behaviors from an attending, how that dean responds will actually portend the mental health of that medical student. If the dean responds appropriately and like takes that attending the task or has them redo trainings or removes them from like taking care of patients or removes them from training trainees that medical student will then feel protected by the university and then actually have better mental health outcomes. However, if that dean does not take that person the attending the task or does not remove them from care or says, what was, why are you the problem for that medical student? Their medic, their mental health will actually get worse and that's been played out in studies as well. Regarding patients in 2017, Fitzgerald looked at vignettes to examine the influence of patient characteristics on attitudes, diagnoses and treatment decisions. What they saw in 35 out of the 42 articles, they found evidence of implicit bias. This included bias around race age, socioeconomic standing, mental illness, weight having aids, patients who have experienced brain injuries, people who use intravenous drugs, substances, disability, social circumstance and gender. So they basically what I was talking about before, there's bias in everything. There's actually the same levels of implicit bias as the wider population. If you took America and shrunk it down to a hospital size, you'd see the same exact rates of discrimination playing out. So how do we work in our hospital system to deconstruct that? And how do we think more broadly about using our position as physicians to speak about that more openly when physicians were less certain of coronary artery disease diagnoses for middle aged women, they were more likely to give those women mental health diagnosis compared to men. This also sadly plays out regarding residents who are minor ized. And so in 2016, Lecy looked at bullying. So these are repeated acts or practices directed at one or more workers unwanted by the victim, done deliberately or unconsciously but clearly cause offense, humiliation and distress and may interfere with job performance and or cause unpleasant working environments. Some examples of this are unjustified criticism, humiliation in front of colleagues, intimidatory use of discipline or competence procedures, undermining personal integrity and shifting goalposts, shifting goalposts. The example for this is a medical student comes and says to their attending on the first day. Just wondering like I wanted to talk about the rotation. I was also wondering how like you achieve honors on the rotation the attending says you need to do X Y and Z med student does X Y and Z. The attending then says you need to do A B and C as well. Student does A B and C. Then the attending says you need to do D E and F Met student does D E N F, it goes on from there. And so what the attending is doing is actually moving the goal line. So that person will never achieve honors. 69.8% of residents in the US said they experienced workplace abuse. The most common form of abuse was verbal in nature in terms of types of resident mistreatment and themes, there was a lot of hierarchy. So that's why I tell people to call me chase. We are all colleagues, we are all in this together. So let's try to flatten the hierarchy as much as we can. They also saw a lot of silence of people saying that they like didn't they were keeping things to themselves because they didn't want to speak about it openly because of feeling unsafe. It was incognizance. So not knowing what was happening to them. Sometimes there's also fear. So 79% said they were afraid to report events that happened to them. There was also a lot of acceptance and denial. So saying what happened and what to me wasn't that bad or this is what everybody in medical school goes through or what happened to me, wasn't that big of an issue. There's also a legacy of abuse. So there are studies around if a med student is abused by an attending when they first or a fellow or higher level trainee at the time, if that med student isn't protected later on, then they will go on to be more likely to actually abuse medical students as well. So just thinking about how do we break that cycle of abuse. There are also studies that show that if a medical student comes in and they are not taught about like implicit bias and they're not taught about microaggressions or minority stress or things of that nature. When they become 1/4 year and leave medical school, they're actually more racist and more biased than they were previously. So how are we training our trainees? It's a big thing to think about Lucy also looked at the sequel of resident mistreatment. It plays out on the individual and systemic level. There's a cost to the system with higher rates of medical errors, harm to patients and dissolution of care. 67% of people who witnessed disruptive behavior felt it contributed to adverse events. There's also sadly a cost to the individual as well. They saw higher burnout rates, thoughts of desertion or leaving the program, depression stress. There are actually studies coming out that what medical students or trainees or residents go through if they are abused actually causes PTSD or post traumatic stress disorder symptoms, including nightmares, as well as hypervigilance panic attacks when they have to go back to the hospital. So thinking about what are we doing to trainees and how is it for them to even be in the hospital and keep re traumatizing them by having to go into a space that's unsafe for them. They also saw higher rates of substance use and suicidal ideation. 20% of the people said that they would not pursue medica medicine again and several would advise others not to pursue. So we have a lot of work cut out for us unsurprisingly for minor ized trainees, things are worse. Um So Justin Bollock, who you should all read his articles. He is phenomenal and speaks openly about living with bipolar disorder and mental illness and he's a now nephrologist at Nephrology Fellow at U W into 2020. You did a study that looked at minor fourth year medical students, what they saw was this thing called stereotype threat. And so this is more of an internal thing. So I want you to all think about minority stresses, like other people doing things that then cause like internal things to happen to you. Stereotype threat is more of an internal thing that gets activated because of all those outside forces in terms of what stereotypes specifically is. It's the thing where basically when you enter a rotation or you enter a room and you start to think to yourself like I don't want to play into the stereotypes that other people might have of me, which then makes you more anxious and makes you more feel like you're under threat. Basically, they also saw higher supervisor biases for minor residents and trainees and possibly poor, poor prior academic training as well. This can be triggered by standing out or being seen as standing out. So even if you like know that you're attending is safe, if you are the only like minor person in a room that actually can make you feel that stereotype threat. And so you start to worry about how you're being perceived by others. You also, they also saw a lot of reliving past experiences. So even if a rotation went well, just the fact that somebody had had a previous traumatic experience, it causes a ripple effect for them in their other rotations and witnessing microaggressions causes by proxy trauma. So this is why when people share videos of like minor people being injured and things like that, that actually is really re traumatizing people as well. Nonwhite students were also noted to be receiving less favorable medical student performance evaluations and lower grades as well. So just thinking about how our own system enacts these things too. So these are some anecdotes that we gathered from people back in residency blank. This was a nurse voicing concern that a black patient was dangerous because they were listening to rap music loudly while pacing the unit. This is an example from a friend who is a social worker. He is African American and gay and still remembers this event. This happened on another team with a different resident and a different attending. So an elderly Hispanic man was admitted for dementia psychosis and paranoia. The treatment team was rounding with the patient in the IC U. The patient became very agitated and angry because in his psychosis, he believed I had assaulted him at the facility where he lives. The Spanish interpreter reported that the patient was making racial statements and wanted me to leave the room not knowing how to correctly respond. The resident gave me a look that seemed to suggest that for the sake of the interview, I should leave feeling shocked by the resident's response and lack of response from the attending. I felt I had to do what was being asked. Needless to say I felt unsupported stigmatized and invalidated. I believe the resident and or the attending shift told the patient that I was part of the team and we need to stay. There was this thinking back in the day in training and this is something that my class like went up against a lot that when a patient is having a psychotic episode or they're having an like an episode where they're saying racial slurs or homophobic slurs or like discriminatory slurs that's ok. And like you should just deal with it because it's just somebody who's like not feeling right. Right. Then what we talked about was just because somebody is not feeling well at that time does not mean that they should be able to say discriminatory things towards somebody else and we should be able to set limits around that. So that's what our class started doing. Um The other thing to think about is how do we protect our team members when these events happen in this situation? Thinking about why did the team not say it's clear that this is not working well right now and we will come back when you're able to respect our colleagues more appropriately and then step out of the room at that time because there is no acute danger happening at that situation. So thinking about how do we protect our trainees and other team members so that they actually feel seen and validated. There were also differences in residency and attending evaluations when colleagues stated that the minor colleagues worked twice as hard and were twice as good. This happened across our residency and was actually something that we had to take on as well. People who are minorities being interrupted by attendings when others who are not, minorities were not interrupted on rounds, minor individuals being told their answers were wrong when they were reciting directly from the reading, there's also the minority tax. So this is something where a medical student or somebody comes in and they're minor and immediately they're tasked with heading diversity teams. They're tasked with talking about diversity, teaching other people about diversity. I am able to do this talk with all of you because like I, I am in a place where I feel comfortable talking about these things and being open about them. However minor ized people are often put in this position and they feel as though they have to talk about these things even when they don't want to. So thinking about the how we tax people when they should be able to just be medical students or trainees, there's also tokenization. So this is something where like if you think about diversity, like and how it plays out in universities, there's usually a diversity page and then it has like all the minorities people which are like usually three or four of them splashed across the website and they use the same pictures or the same people across those things. So tokenize somebody is basically saying like, oh, we support diversity here. But if you actually ask those trainees or you ask those people, they'll say that they usually don't have the power to like enact changes in the way that they need to. There was, it was also noted that residents were feeling and sometimes made to feel as though they are the problem when they bring issues to the fore. And there was an attending who for another colleague said that he had worked so well with African Americans before. And they worked so well together when we all checked this later, that was actually not true for other African Americans who had gone through the program. They said that the experience was horrible. So, perception and intent is also important. We also noted and heard about weight staff who were minorities being told by a white patient that they could finish the food left on a patient's tray, minor weight staff were often being told instead of asked what to do in the room by white physicians. There's constant misgender of transgender patients and saying when rooming them, well, they're not actually a female. We need to think about the safety of our patients who have trauma for men. A sign out email saying that because a black person or because the person had trauma with an African American person in the past, do not room with a black person instead of moving that person with the issue. And also staff sometimes saying that clearly that person has a personality disorder and noting it occurs often with LGBT Q plus patients to describe what a personality disorder is. It's something like some of you may have heard about like borderline personality disorder and narcissistic Personality disorder. These are like personality structuring that occur in psychiatry and that we diagnose. And so when somebody is young and they go through trauma or certain types of experiences, they have a way that they structure their personality in order to like adapt and move through things later on as they get older, however, they still have that personality structuring and then it became, can become damaging to their relationships as well. However, what we noted and what's actually been studied is that a lot of LGBT Q plus people who are experiencing very real things like trauma or they're experiencing things like minority stress instead are diagnosed with a personality disorder. But if you go through the strict criteria, they don't fit the criteria for being diagnosed with a personality disorder. So even how we diagnose people for who are minor is very important to think about. So we also heard that hearing a patient is difficult or aggressive and sure enough, they're a minor person. When you look at notes and seeing how race is brought to the one liner for specific patients, you won't see a lot of pay like one liners that say like 58 year old white male. However, you will see notes that say like 58 year old like African American male, there are studies about how that actually already predisposes you to think a certain way about like somebody who is minor before you even enter the room and can cause bias to enact already. So thinking about how we like label people and why we're using certain labels and how they're useful versus not and how we chart things too is important staff and patients also know how there are no pictures of minor physicians on the walls or from minor staff members. How are people seen? How are different types of families and different body types and different people represented in a hospital system? I think Benny does a better job of that. So just gonna put that out there. So how do we help? And how do we grow? The first thing we do is we ask there's a caveat to this. So when we ask people about their experiences, we need to always give them an out because some people do not want to talk about racism. They do not want to talk about discrimination. I am ok with talking about it because I know how to talk about it and I know how to close conversations back down. If I need to. Some people this will open them up in ways that they might not have ever talked about this. And so that can be really damaging for them. The way I do it with kids when I first meet them is I ask if they identify as any like minor ized category in America such as being LGBT Q plus or racially minors or religiously minor. And then I leave it. And then later on in the conversation during our first intake, I will say because you identified with this category in America, we know that America is a mess and there are times that you might experience things where you like see things on the news about like you and your identities that make you anxious. You might see things in newspapers that make you anxious. You might hear things at school that cause you to start feeling more anxiety or you've been attacked directly because of your identities. You don't have to tell me specifics about what happened to you because I don't want to open you up too much right now. However, I am here as a space in order to talk about that as time goes on, that has helped a lot of kids either come out to me or start talking about like stressors they experience for the first time in their lives, but it gives them an out in case they don't want to talk about it as well. We need to educate ourselves and not always expect our patients to educate us and then protect minor ized people. There's this danger of being becoming false allies. So when George Floyd was murdered, a lot of people started posting black the squares to Twitter and things like that. So what does that actually do? What is that actually helping? That's just symbolizing like, oh I'm saying that I'm an ally, but what actual ground work are we doing? And how are we changing policies at universities and changing conversations with our friends and family members around discrimination. We need to come at this from humility, from seeking to understand and truly converse. We're not gonna get this right every time. And so it is OK, it is ok to say, I'm sorry, I didn't do a good job with handling that issue. I will do better. And here's how we also need to believe minor as individuals when they bring these issues to the fore as well. So how do we heal li see the this article from 2016 is like really brilliant. Um They actually looked at how there are different steps to healing and how this can help minority, not minor trainees but trainees in general. But it does map to helping minorities trainees and people in general. So education awareness, they saw that lead led to decreased bullying. So all of you coming on this talk and just picking up one new term will help you be more aware and able to combat things and talk about them a little bit more with your patients and with other people as well. Team based care at all levels led to a reduction in the hierarchy and good leadership led to prevention and protection and to find a better culture, inter physician support led to better fostering and mentoring. And also they saw a need for confidential mental health services. There also needs to be a development of a curriculum that tackles the hidden curriculum. So half a medical school in like training is learning medical facts. The other part is social navigation. Why do we not have lectures on how to socially navigate discrimination and navigate the medical system in general, we also need standardization of feedback as well as safe mechanisms for reporting. And then in the worst case scenarios, we need to build exit strategies. So this is basically saying that like if a university is not able to help somebody who is minor or help them heal or actually protect them, how do we get them to a university that's safer without blowback for that actual individual. We also need to recognize name and understand these attitudes and actions, identify our own implicit biases and we need diversity training. That's not just about diversity now, but also diversity that happened back in the day and things that like the medical system has done to people who are diverse because we keep repeating similar patterns where we say we'll do better and then we start enacting more discrimination and then we're like, we'll do better. And then, so how do we actually move forward in the ways that we need to? We also need continued research that address the patient's social risk factors and needs and we need a more diverse health care workforce. This has a caveat. So back in the day, the thinking was let's bring in more minor trainees. What's been noted is that if you bring in minor trainees, they do not have the power to change things in the ways they need to. Yes, they do change things. But a lot of them that's building a pipeline in and then they burn out and then they leave that university in the end. So how do we actually bring in people who are deans de, people who are faculty who actually have the power as minorities people to like actually protect minorities, trainees as they come through. How can minor ize people protect themselves? So thank the Goddess Ariana Grande. They're actually techniques and strategies to protect somebody. So they noted that reflective coping and problem solving activities in about 100 and 34 studies about discrimination and health outcomes, this led to better mental health outcomes and physical health outcomes. For them. This included things like cognitive restructuring. So helping somebody reformat and process the event that had happened, simple expression of emotion. So saying like that was a horrible event and letting that person share about that is important too and social support seeking. So thinking about what environment does somebody have, what community does they have that supports them and validates their experiences. They also saw the importance of community and central identity. Central identity is this thing where if somebody is LGBT Q plus, how are they feeling pride in their identity? How did they feel solidified in their identity? Do they like have LGBT Q plus friends? Do they have mentors who are LGBT Q plus? Do they get to go to events that are LGBT Q plus? Friendly thinking of like how does that identity actually weave into like how they express themselves, how they are like able to like express themselves in the general world with their family, things of that nature. They also saw the importance of social support, spirituality and religion, humor, role, shifting, armoring, cognitive restructuring and a bunch of other things as well. No, but chase, we need specifics. So the A P A, the American Psychiatric Association actually looked at how to disarm racial microaggressions. So some of the techniques that they saw were making the invisible visible. So saying, like I'm wondering if I'm making you uncomfortable, there's also disarming the microaggression. I don't agree with what you just said. So very short sentences because if you get two in the weeds with it with people who are enacting these behaviors, then it becomes like this conflict back and forth and what you're doing is just setting a hard limit of like I do not agree with this. I'm not going to deal with this. I'm gonna caveat all the things that I'm telling you right now about this and that some of them will work in certain situations and some of them will not. And so part of it is learning what works in what situations and how comfortable you feel to use these different techniques. There's also educating the offenders. So saying like I know you mean well, but what we are actually gonna focus on is like this issue instead of what you are trying to focus on with your discriminatory behaviors. Some other techniques are seeking external intervention. So having somebody who is trained in this coming in helping and evaluating how things are done at a university or academic center setting clear limits such as we cannot tolerate that kind of language redirecting and reframing people is also another technique. This line is a little bit busy, but I just wanted to show you this is what the A P A put together in terms of actual techniques. And this dives more into like the actual steps and things like that in terms of future directions of thought. What are some ways that we can protect people of minority status when they enter institutions where minority stress happens further research into minority stress in female and other U R M populations is necessary. How long does it take roughly for people who have experienced minority stress to recover? What are ways in which they do recover and don't recover? What aids in that recovery and how they protect themselves in the future when entering an environment that's unsafe for them? How do institutions facilitate productive conversations? What is our role in speaking to these topics to a larger audience and standardizing study methods and terminology is important too? So we're gonna go back to that Vignette that we talked about at the beginning. So how did that Vignette, we began with end, I flew to San Francisco and cried in my apartment that night from missing my friends, relief that it escaped an unsafe environment. And over the loss of my once dream to stay in Boston forever with my friends. Over the next weeks, I took time to myself to reflect, to look to the future. A few weeks later, I revealed my true identity on Twitter because I felt safe. And I began my fellowship within weeks of my arrival, the depression and suicide vanished. And I entered the third remission period in my life. I found a program where my program director said to me, I'm Caitlin Costello. She's amazing. I always give her a shout out now. Um You never have to take on issues with racism if you don't want to, it is not your job to handle these things and back that up with words and actions. I got to work with co fellows who spoke up around instances of discrimination before I had to say a word. I also had the opportunity to work with mentors who looked like me who focus on what really matters, helping kids, their families and our world. After seven years, I finally found overall safety and broad support in academia. I began to live fully again. So these are pictures from like fellowship into now and as well. Um I got to again, more fully become that unicorn Phoenix nicknamed Dream by his friends years ago. I'm different but similar in the important ways to me. I've had time to work on articles around minority stress, do lectures at other universities including in lectures here um engage around topics of diversity by choice and not for survival. Skip down the street listening to K pop go gay clubbing, sit and simply breathe, build a family here with friends, old and new and be fully present. When I see friends in Boston and my family in Seattle, I've been able to see just how far someone can fly when not constantly barraged by discrimination. I found an environment like the one I am in college and graduate school where I feel safe, the scars are healing and it will take time. But those cracks are healing and I couldn't feel more fortunate because of all of that. I just graduated from fellowship at U CS F and decided to stay as faculty as an assistant professor which some of you know, I've been shortening to that to something that's like a little inappropriate. So I'm not gonna say it here. Part of my work with others is building a clinic specifically for minority youth that will involve narrative therapy, trauma focused therapy, healing from discriminatory trauma teachings and groups for parents and kids around discrimination and mental health and collaborations with other clinics in honor of the friends, family mentors and people I love who once saved my life. Once upon a time, the clinic will be named after a group nickname that started in college and grad school. We will be calling the clinic, upcoming clinic. The might use this clinic for minor youth. And I'm excited to see where these new chapters that I get to write with. All of you. Take us with special thanks to Mark. I always give him a shout out because we built this project at the beginning together. It's been like, obviously, it's been very adapted from there, but I always give him a shout out and then also for Christina and then Doctor Raja and then Dr Yun, who put us in contact in the first place and Benny off for inviting me as well and all my mentors past, present and future and this is sort of cited and this is my contact information. Thank you so much, Chase. That was really incredible. I um for all of you in the audience, I first heard a very similar talk. I think I was an intern probably or a second year and I, I just knew I had to hear it again and I could listen to it like year after year. Uh So we do have a couple of questions um as an attending, this is coming from an attending. How do we balance inquiring about identity without exacerbating the feeling of being minor for a trainee? And how would you recommend wording an invitation to share more about oneself while giving permission to not participate in the conversation if they don't feel comfortable? I love that question. Um That is amazing and I really appreciate that you're asking that um the way that I do. It is when I first, like now, now that I'm working with med students and trainees and like residents and stuff now, which is so weird to say as an like new attending. Um What I do in the first day is I actually sit them down and we talk about like what their goals are for the like, basically for the um rotations. I'm like having word finding difficulties now. Um And so then I also just talk about like I talk about my own identity a little bit. Um A lot of the like trainees I work with have actually read articles I've done before and like that was something I had to navigate as well. But I also will then talk about things like what do you not only want out of the rotation but like part of my job is to help you be the physician that you want to be and that's all aspects of your identity. And then I say, like, you don't have, have to tell me about this. But are there aspects of your identity that maybe haven't been praised in medicine? But you want to like really highlight or bring into the room with you? And so then that gives like license for the trainee to share like, oh, like I identify as this or like da da da. And I also always give them an out by saying like these are hard topics and like, I want you to be somebody who is a trainee that gets to bring all of yourself into the room. And I want to know what does that mean to you. You don't have to tell me now and that's going to be an ongoing thing and ongoing shifting conversation as you like, figure out your identity and like as we work together. But I am here for those types of conversations too because you are clearly skilled. And so it's not only going to be about medicine but who you want to be inside of medicine. Um That's one of the ways that I go about it. And I've seen that work pretty well so far. I mean, I haven't gotten my evaluations for like working with trains, but I hope they're good so far. I've asked them for verbal feedback and like, just because I think we don't ask for feedback as attendings that often. So I'm trying to change that paradigm and they've said so far that like, it's created an open, like more open space for them to be themselves. Um The thing too is I also self disclose. Um sometimes like I will say, like, I will ask um like med students and trainees and stuff about their pronouns at the beginning. And then I will share mine and say, like, I also identify as African American and gay. I lead that. So then they feel a little bit more comfortable with like sharing about themselves later. On too. Um Those are some ways that I go about that. Thank you. Sounds like um you know, leading by example and creating a safe space is the way to go. Um While you, while I ask the next question, could you pull up your contact? Yeah. Um I can actually, can I print the chat that might work? Yeah, I think so do it. And the next question is, um, you have covered so much scope uh today. Um But also wondering if you have a perspective to offer as a psychiatrist on the potential intersectional experience of neuro divergence such as our colleagues with a DH D autism. Um in our trainees and workforce, this seems to be a largely silent minority identity in health care. That is, I really appreciate this question too. Um There are plenty of people that I have worked with who are premeds who say to me like I'm scared because I have a DH D or I'm neurodivergent or like I have some autism, like some facets of autism. And these are sometimes not only premedical students, but I've worked with like trainees who were like, I can't share this because I've been told not to. So the big thing that I think about is how do we talk more openly about this? This is like, why I love psychiatry is like it all comes back to the story and like also thinking about how are we creating an environment where it's safe for people to share. So when I share my identities, I also talk about like, hey, I know that also like some people are neurodivergent. Some people like learn differently. Some people will need to speak differently. Some people will need to like move differently through the rotation. So if there are aspects to yourself that like are different, then like what is considered norm because I like put in quotes because norm is like, what does that mean? It's like not, it's a useless term. Um Or there are ways that you learn that are better for you or you have learning like differences. Please let me know because this is something that is part of my job is to also make sure that you can learn the ways that are necessary for you. And if there's something that comes up and you react in a certain way, then I will like, I am here to support that because that is context for me of like, this might have gone this way because of this. Um The other thing too is I think we need more like as much as people feel comfortable and are in a position where they're able to speaking openly. That's why I started talking about my own minority status and articles too because I not only felt safe, but I was like, I was on Twitter and I saw all these people who were minors in different ways being like, I can't be open at my university. I can't talk about this. So that's why I started talking about it too because I was like this hopefully will help people um and help people not feel like they have to be silent or silenced. The other thing that we need to think about is if somebody is open about being neurodivergent, how do we respond? How do we support them and how do we make them feel safe? And if something bad happens to them, who do they have to reach out to? So just thinking about all those factors too, I completely agree with you. Neuro divergence is something that is very prevalent actually inside of like academia, people just don't talk about it as much. So changing that conversation by people being open as well as us being open about how it's something that we want people to be able to discuss more is how I kind of come about it. Thank you. I think we have time for this one last question. Um How or when do you document somebody's minority status in your psychiatric formulation? I love those questions too. You're all asking amazing questions and just thank you for being here. Um So what I do is I actually put in part of my intake interview. Um So I actually have a line that says like, like um being minor ized or something like that and it's just like that. And then I, that's when I asked the question. And then I put in like how they identified as being minor. And then underneath that a little bit farther down inside of the social history, I'll put a line that says minority stress. And then if they say yes or no, then I'll say like, no, like this is how they deal with it or yes, this is like, how it's come up for them. And then I actually, like, this is something I started in residency because like, by my third year, I was like over it and I knew I was leaving and I was like exhausted and I was just like, they keep telling me to be a blank slate and not to do things and not to talk about these things and I just was over it. Um So in my notes, I started putting like major depressive disorder secondary to minority stress. And so then it carried forward inside of notes so other colleagues could see it because I remember a colleague came up to me and they're like, I love that you put that in there. And I was like, it's my subversive way of like changing the system, hopefully. So I put it in there. But I also ask patients if they're OK. Um If I put it in there because some of my patients are like LGBT Q plus and they're coming out for the first time um because they like, see my hair and they're like, OK, like we can go ahead and I can like, be as gay as possible. But then I have to ask them, like, who have you told? Have you talked to your parents about this? Have you talked to other providers about this? And then if they haven't, then I have to like, fiddle with it and leave it out or I ask them how they want it noted in their chart. So giving people back their power and ownership because when somebody comes into the hospital, is it already like disadvantaged and like hierarchical position in some ways that exposes them to a lot of possible previous trauma from the hospital system or just exposes them in ways that are uncomfortable. So there is a power imbalance and so trying to give them their power back by saying like, how would you want this documented is something I ask patients to. Awesome. Thank you so much. Thank you for everyone in our audience. Those excellent questions. Thank you so much, Chase and we look forward to seeing you again in a few months. Everyone has a good week. Take care. Bye everybody.