Guest Perspective – AM Rounds Beyond the pages of Academic Medicine, journal of the AAMC Tue, 18 Jul 2017 11:00:40 +0000 en-US hourly 1 Tips for Reporting P Values, Confidence Intervals, and Power Analyses in Health Professions Education Research: Just Do It! Tue, 18 Jul 2017 11:00:40 +0000 stethescope and medical chart 2

By: Colin P. West, MD, PhD, Eduardo F. Abbott, MD, and David A. Cook, MD, MHPE

Basic statistical results, including P values, confidence intervals, and power analyses, are variably reported in scientific publications and frequently misunderstood or misapplied. In our current article, Abbott et al, we examined the current prevalence and evolution over time in reporting of P values, confidence intervals, and power analyses in health professions education research (HPER) publications.

We found reporting of P values and confidence intervals in HPER publications increased from the 1970s to 2015, and in 2015, P values were reported in most HPER abstracts and main texts of published research papers. However, reporting of confidence intervals and power analyses remained uncommon and lagged behind reporting in general biomedical research. In addition, most reported P values were statistically significant according to the standard threshold of P ≤ .05, which seems likely to reflect selective (biased) reporting.

Several general recommendations stem from these results. First, more detailed quantitative reporting of key statistical results is needed in both abstracts and main texts of HPER publications. Basic descriptive results (which, depending on the situation, might include group means, proportions, and/or effect size measures, such as differences between means, relative risks, odds ratios, regression parameter estimates, and correlation coefficients) should be reported to allow readers to evaluate educational or clinical significance, which is not automatically conferred by statistical significance. Notably, it remains common for P values to be reported without these basic results, especially in abstracts. In addition, confidence intervals offer far more information to readers than P values alone, and the fact that only a minority of HPER publications report confidence intervals represents a methodological limitation the field must improve. Confidence intervals around effect size measures are particularly important (i.e., more important than confidence intervals around the group means or proportions). As the abstract may be the only part of a publication many readers will review, it is important that these core quantitative results be included there.

Second, selective reporting of (typically) positive results provides a biased view of scientific investigations and their results. We recommend all analyses planned according to the research protocol be reported, ideally in the main text but at least in supplementary files. Of course, this requires that a research protocol exists to guide the study and analyses in the first place. To further reduce this bias, authors, reviewers, and editors should avoid automatically dismissing “negative” studies, and base their appraisal on a study’s scientific relevance and methodological rigor, including reporting of confidence intervals.

Third, sample size and power considerations remain quite uncommon in HPER publications. These should be integral elements of research protocols and reports. The fact that most reported P values are statistically significant, despite low power, for the majority of published HPER further highlights the degree of publication bias likely affecting the field.

Although there is progress to be made in HPER reporting it is notable that the reporting of these basic statistical results has generally improved over the last several decades. With continued attention to these issues, we are optimistic that HPER publications can match or even exceed the reporting quality of other biomedical research. We summarize our key recommendations below.


  1. Report basic descriptive results summarizing study data (e.g., group means, proportions, measures of variability).
  2. Report effect sizes (e.g., differences between means, relative risks, odds ratios, regression parameter estimates, correlation coefficients).
  3. Report confidence intervals, especially around effect sizes.
  4. Thoughtfully plan hypothesis tests, and account for all planned analyses in the final report.
  5. Distinguish statistical from educational significance.


  1. Rely on P values alone to report study results.
  2. “Cherry-pick” statistically significant P values for reporting.
  3. Dismiss statistically nonsignificant P values from methodologically sound and adequately powered studies.
  4. Conduct and report power analyses after data have been collected.
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The Unstoppables: Undocumented Students in Medical Education Tue, 27 Jun 2017 11:00:09 +0000 hands in go team formation

By: Raquel Rodriguez

R. Rodriguez is a first-year family medicine resident, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.

At eight years old, my first glimpse of the United States was the arid land that separates the U.S.-Mexico border. As I sat in the car waiting to be assessed by the uniformed border patrol guards—marveling at the barren land of opportunity—I could not have imagined how crossing this border would transform my life. My new, secretive existence would make the simplest tasks into unusual challenges. As an undocumented student, turning sixteen came without a driver’s license, turning eighteen came with no reassurance that I would be able to attend college, and my first trip home as an undergraduate was plagued with anxiety as I handed my student ID to airport security. Fearing deportation, I guarded my secret and focused on my education.

In recent years, not unlike me, many undocumented students throughout the country have found themselves without clear hope for the future. Their ineligibility for employment having hindered their efforts to pursue a medical career. Despite their unrelenting persistence, their achievements in the classroom, and the support of entire communities, the dream of attending medical school seemed out of reach. I met many of these hopeful students as I searched for one who had successfully matriculated into a medical training program. I found none. Nonetheless, their stories of resilience amazed me and provided me with the motivation to investigate further.

Counter to the advice of premedical advisers, I applied to medical school. At the time, their concerns were valid and quite serious: How will you pay for medical school when your immigration status makes you ineligible for federal loans? What will you do after graduation without employment eligibility?

A medical program took a chance on my application, and I began my studies in the fall of 2011. As expected, financial challenges persisted, but a significant reprieve arrived shortly before my third-year clerkships. The Deferred Action for Childhood Arrivals (DACA) program was implemented. Via this federal memorandum, I was finally allowed to obtain employment authorization, a driver’s license, and an identity of belonging in the United States—benefits that had eluded me since my arrival in this country almost twenty years ago.

Since the DACA program was established, many medical schools have officially opened their doors to DACA recipients. While these talented students currently make up a small percentage of medical students, their stories have impressed me with their resilience, creativity, and humility—traits that everyone would value in their own physician. As described in the article, “Considerations for Residency Programs Regarding Accepting Undocumented Students Who Are DACA Recipients,” the next step is to facilitate their continued medical training.

On the days when my commute to the hospital provides me with time for reflection, I think about the undocumented students I have met and how my achievements are inspired by their stories. These students have given me hope. Now, I can only dream that the communities they call home will give them the precious opportunity to see an America that is not arid, but one that has tall buildings, resplendent streets, and where their dreams will know no boundaries.

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How Prepared Are You to Lead? Tue, 13 Jun 2017 13:21:17 +0000 EKG rhythm with light bulb

By: Peter Pronovost, MD, PhD, and Christopher Myers, PhD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine

Physicians increasingly are being asked to lead health systems and improvement efforts, so it is important that they have the necessary skills to do so. To see why and how these leadership skills matter, we propose a quick test. Below, we present three scenarios that a health leader might need to navigate. As you read these scenarios, we encourage you to reflect on whether you have a framework you could use to address the issues described, whether you have all of the necessary skills to address these issues, and whether you have a commitment and mechanism to grow and develop these skills.

Case 1: You were just hired as a new attending in a surgical division. A nurse comes to you confidentially to raise concerns about the quality of care provided in the division. The nurse does not want you to discuss the issue with others, because she fears she will suffer retaliation. She states that there is a strong culture of fear and distrust. What do you do?

Case 2: You are leading a project to introduce a new pathway for managing heart failure patients. You bring together the academic and community cardiologists and the primary care physicians. The main academic cardiologist says he wants to make the pathway as he is the world expert. He drafts a pathway and hands it out at the first meeting. The other physicians feel disrespected and do not want to participate. You are under pressure from your hospital leadership to implement the pathway and reduce practice variation. Yet the physicians do not want to join. What could you have done differently and how might you recover?

Case 3: You recently have been made the chief quality officer of a hospital. The boarding time for patients admitted through the emergency department is very high, and your Board and leadership want you to reduce it. You understand that it is a complex problem involving multiple departments. You also know that the interventional cardiologists and surgeons do not want emergency department patients to take their beds–they want to be able to accept transfers from outside hospitals. You call a meeting to work on the problem. How would you motivate the different departments and lead the change effort? The lead medicine physician and surgeon say you do not even need a meeting because the emergency medicine patients are a low priority. How do you approach the problem and get them on board?

All three of these cases illustrate issues of trust, teamwork, power, and change in organizations. These are issues that all leaders face every day, yet they are not the issues that physicians are trained to address. In all three cases, an understanding of leadership and organizational dynamics could provide the frameworks and tools to successfully navigate these challenges.

How did you do on the test? Did you feel prepared to handle the situations? If you need more training, where will you get it?

While we believe these topics need to be incorporated into the medical school curriculum, for physicians who are already in practice, we suggest looking for opportunities at business schools (particularly for those physicians at AMCs affiliated with large universities). Increasingly, business schools are offering specialized courses and opportunities for developing the leadership skills needed in health care. For instance, at Johns Hopkins, we offer a specialized five-day Executive Certificate in Health Care Leadership and Management, which is open to health professionals from any institution and offered for continuing education credit. This program brings together health leaders and management experts to develop the kinds of foundational skills and abilities described in our Academic Medicine article.

In addition to formal training, ongoing skills development through peer or formal coaching is also important. This training can be practical. For example, ask a trusted colleague to provide feedback on your performance in a high stakes meeting. Did you listen to others’ concerns? Did you align around a common interest? Did you reduce resistance? Whatever the source, though, it is never too late to develop these critical leadership competencies, and, by doing so, we can improve the quality of care we provide.

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Reaching the Same Goal Together:The Importance of Medical-Legal Collaboration Mon, 29 May 2017 17:00:46 +0000 hands in go team formation

Editor’s Note: For more about the interprofessional program described in this blog post, check out this Academic Medicine article.

By: Elizabeth Wedegis, Georgia State University College of Law, 2017 Graduate

Though I first joined the Health Law Partnership (HeLP) Legal Services Clinic to gain practical legal experience, I am leaving the clinic with much more, including a better understanding of how both medical and legal professionals have the same goals and can better accomplish those goals together. Lawyers and doctors do collaborate in some instances: when a lawyer needs a medical expert opinion to prove a case, or when a doctor needs legal advice regarding risk management of patient care. Learning to work together as students, however, will prepare lawyers and doctors to address the social determinants of health together.

Each profession is person-centered. In law school, we are taught how to help each client through diligent research and compassionate client communication. In the HeLP Clinic, we see what medical students are taught by participating in classes at Morehouse School of Medicine, attending patient rounds at Children’s at Hughes Spalding, and sitting in on case deliberation in the resident workroom at Hughes Spalding. Both boil down to a fundamental goal: The client/patient comes first.

During patient rounds, I saw how medical professionals provide for their patients, through both medical technologies and through emotional consideration. I remember one patient, a baby with feeding issues, who had previously visited the hospital due to weight loss. After a couple of days in the hospital, he gained weight and was doing better. The doctors suspected an issue at home and called the Division of Family and Children Services (DFCS). DFCS decided the child should stay with his mother, so he was released to her care. When the child returned to the hospital, the doctors pushed harder for DFCS to find a foster home for him. While recounting the patient’s backstory, the doctor explained “it’s not about [what] the adults [want], it’s about that child in there.” That resonated with me as another reason for collaboration between doctors and lawyers. Both focus on what is best for the individual. In two such person-driven fields, it is important for each to listen to and learn from the views and techniques of the other.

Both professions also strive to balance providing facts and staying compassionate. A doctor once explained to me that, as physicians, “we are scientists, we give the facts,” even when they are not what the patient wants to hear. She and another physician spoke about how some residents are hesitant to include “obesity” as a pregnancy risk because they anticipate a patient’s negative reaction. But, as the doctor explained, it is a risk and, because they must give the facts—it must be added to the chart along with other pregnancy risks that derive from obesity, including heart issues and diabetes.

Similarly, in the HeLP Clinic we have discussed how to handle closing a case when an analysis of the legal requirements for receiving Social Security disability benefits and the medical records show that a child is most likely ineligible. Though providing the facts is an essential part of both professions, compassionately explaining those facts is equally important. I plan to apply what I’ve learned in the HeLP Clinic to my future practice by collaborating with other professionals from the start of each case because, when we have a common goal, working together will always be more rewarding for both the professionals and the client/patient.

Author Reading: The Stranger in the Room Thu, 18 May 2017 11:07:40 +0000 A new episode of our podcast is now available through iTunes. Listen today.

In this episode, Dr. Nancy Angoff reads her essay, “The Stranger in the Room,” in which she compares connecting with patients in the exam room before and after the advent of electronic health records. Her essay was published in the Teaching and Learning Moments column in the May issue of Academic Medicine.

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“My Husband Qualifies for Sainthood”: Balancing Relationships Through Residency Training Mon, 15 May 2017 11:00:13 +0000 medical family

By: Brenessa Lindeman, MD, MEHP, fellow, endocrine surgery, Brigham and Women’s Hospital, Boston, Massachusetts.

“My husband qualifies for sainthood.” Anyone that has ever met me and inquired about my life outside of the nearly all-encompassing sphere that is residency training has very likely heard this phrase roll off my tongue. While it is spoken in a lighthearted manner, it belies the seriousness with which I feel this sentiment. My spouse (who is a professional in a field outside of medicine) did not choose this career path and has occasionally struggled to understand why I chose to endure the seemingly never-ending years of sleepless nights, hopelessly inaccurate estimates of when I might leave the hospital, unbreakable tethering to my pager and smartphone, and frequent interruptions throughout dinner and our shared night’s sleep.

Yet, despite my inability to fully explain the magnitude of why it is important to me, he did endure all of these things, and countless more—particularly after we embarked on the journey of parenthood. He did so willingly and graciously, and I truly believe that it is only because he did that I felt so ready and able to weather the up and down storms of a resident physician’s life. His unwavering support allowed me to be free from worry about the laundry, each month’s bills, or what we might eat for our next meal, and instead focus on honing my diagnostic acumen of an acute abdomen, refining technical skills for complex procedures, and struggling to coach and mentor my more junior counterparts.

For all of this, and so much more, there is no individual that merits higher status in my life than him. And that is why I read the article by Law et al with so much interest. They have helped bring light to the inextricable and exceptionally important support networks that all of us rely on—but also how particularly important and precariously strained they can become during the period in which a newly-minted physician is molded and refined. I found myself unconsciously nodding along reading their finding that residents worked to manage others’ expectations about their relationships (only my husband can tell you whether I was successful in this endeavor), as well as how we focus our efforts on the most valued relationships, letting “more distant or less-cherished relationships” wither by the wayside. I am certainly guilty of this.

But as I reflect, I’m not certain that guilt is the emotion that I should be feeling. Having emerged on the other side of residency training, I feel privileged to have been bestowed with the professional identity I worked so hard to develop, and I know that my patients deserve no less than a physician fully dedicated to their care and well-being, which at times requires my full attention and presence long after I had intended to go home. Indeed, the hierarchy of patients’, family members’, and personal needs is a delicate and continually shifting balance, but it is certainly one worthy of navigating. As I look toward the future, I am hopeful that the findings of Law et al, combined with those of the many others they cite, will help inspire structural changes in our training programs to optimize residents’ abilities to navigate this balance.

Author Reading: Case-Based Suffering Thu, 27 Apr 2017 13:04:19 +0000 A new episode of our podcast is now available through iTunes. Listen today.

In this episode, Dr. Louise Aronson reads her essay, “Case-Based Suffering,” in which she argues for teaching medical students the pathos and pathophysiology of a patient’s situation. Her essay was published in the Teaching and Learning Moments column in April issue of Academic Medicine.

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Further Reflection on the Original Identity Program: (Un)usual Collaborations Mon, 24 Apr 2017 11:00:16 +0000 CMNH entrance image

Entrance of the Cleveland Museum of Natural History. Photo Courtesy of Laura Dempsey and the Cleveland Museum of Natural History.

Editor’s Note: This post is one of two pieces on the Original Identity program. Read the other post here.

By: Nicole M. Burt, PhD

N.M. Burt is the curator of Human Health and Evolutionary Medicine at the Cleveland Museum of Natural History, Cleveland, Ohio.

Over a year ago, my colleagues and now coauthors at the Center of Excellence in Primary Care Education – Transforming Outpatient Care (CoEPCE-TOPC), at the Louis Stokes VA Medical Center, approached me regarding a collaboration using the Human Origins Gallery at the Cleveland Museum of Natural History (CMNH). They wanted to create an innovative short program on health care disparities for their interprofessional training program, which is the subject of our recently published article in Academic Medicine. The program describes “Original Identity,” a unique approach to the topic of health disparities that was developed by maximizing the resources of both institutions to bring the interprofessional health care learners on a journey that starts with our shared biological heritage then moves to how to apply this new knowledge in their practice.

Fostering health
The CMNH has a simple mission: “To inspire, through science and education, a passion for nature, the protection of natural diversity, the fostering of health and leadership to a sustainable future.” As you can see, we like a challenge. As the curator of Human Health and Evolutionary Medicine, it is my job not only to translate the science of health to the public through my own research but also through teaching. Informal education is now well established as a great way to enhance K-12 education,1 but how often do most adults go on a field trip or discuss an everyday aspect of their job using a new paradigm?

For the Original Identity program, we ask learners to be open to new thoughts and to challenge their beliefs and biases. We start at the beginning with the evolution of our earliest hominin ancestors in Africa and the evolution of Homo sapiens before our eventual dispersal around the globe. But rather than leaving our discussion of evolution there, we continue to talk about how both biology and culture shape the human experience using examples, such as the biocultural construct of race, that relate directly to current issues with interpreting health disparity data, noting that in humans it can be difficult to sort the biological from the cultural or environmental.

Having previously taught gross anatomy to medical students, I was aware that most students arrived at medical school with no training in evolutionary theory or human diversity and rarely take such classes in medical school. To me, the anthropological framework, which focuses on evolutionary theory and human diversity, had the potential to transform how clinicians think and approach their practice. With the Original Identity program, my VA colleagues and I try to guide the learners to incorporate these new ideas into their practice and to identify their own biases. What does it mean that humans are 99% genetically similar?2,3 Similarly, what does it mean that race can be a biocultural construct and yet health disparities are very real?

CMNH exhibit image

The Human Origins Gallery, featuring “Lucy” the first Australopithecus afarensis fossil, at the Cleveland Museum of Natural History. Photo Courtesy of Laura Dempsey and the Cleveland Museum of Natural History.

New collaborations
As a biological anthropologist, I am accustomed to researching and teaching in an interdisciplinary world. My love of learning at the intersections is probably why I’m an anthropologist and why I work at a museum. As such, I seek out both usual and unusual partnerships as sources of great knowledge and opportunity. The world is increasingly connected, and collaborations of all kinds are helping to create hybrid pedagogical approaches that can support the complex and changing knowledge base needed to be a medical professional. I hope more academic medical institutions try something novel by reaching out to museums and other cultural organizations in their communities.


  1. Martin AJ, Durksen TL, Williamson D, Kiss J, Ginns P. The role of museum-based science education program in promoting content knowledge and science motivation. J Res Sci Teach. 2016:53:1364–1384.
  2. Mersha TB, Abebe T. Self-reported race/ethnicity in the age of genomic research: Its potential impact on understanding health disparities. Hum Genomics. 2015:9:1.
  3. Rotimi CN. Are medical and nonmedical uses of large-scale genomic markers conflating genetics and ‘race’? Nat Genet. 2004;36(11 Suppl):S43–S47.
What Inspires a New Approach? A Reflection on the Origin of the Original Identity Program to Address Health Care Disparities Mon, 17 Apr 2017 11:00:03 +0000 Lucy image

Model of “Lucy” the first fossil ever found of Australopithecus afarensis discovered in 1974 in Afar Ethiopia by former Cleveland Museum of Natural History curator Dr. Donald Johanson. Photo courtesy of Laura Dempsey and the Cleveland Museum of Natural History.

Editor’s Note: This post is one of two pieces on the Original Identity program. Read the other post here.

By: Laura Clementz, MA, MS

L. Clementz is training administrator, Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio.

I note the obvious differences
between each sort and type,
but we are more alike, my friends,
than we are unalike.
Maya Angelou, Human Family

In our recent Academic Medicine publication, my coauthors and I describe a short program, called the Original Identity program, which addresses health care disparities as part of the Louis Stokes Cleveland VA Medical Center’s Center of Excellence in Primary Care Education  – Transforming Outpatient Care (CoEPCE-TOPC), one of seven VA CoEPCEs around the nation. We developed this program in collaboration with the Cleveland Museum of Natural History (CMNH). In contrast to some of the traditional approaches to health care disparities, our program starts with humans’ shared biological heritage to focus on how we are similar rather than different.

Reflection on the program’s origin
As part of my role as training administrator within the CoEPCE-TOPC, I worked with faculty to develop learning sessions within the culture and health curriculum. Over the years, I became very aware of the challenges of addressing culture in medicine and the possibility of adding to or reinforcing the stereotypes, assumptions, and negative biases of health care providers by covering a multitude of individual cultures during learning sessions. Within the same curriculum, I also worked with museums to deliver sessions that covered teamwork and patient-centered care to our learners; we are fortunate to be located in an area where multiple museums are within walking distance of our medical facility.

After presenting with museum faculty at a conference that focused on creativity in medicine, I had a thought that it would be an excellent opportunity to work with our closest neighbor, the CMNH. In thinking about what kind of activity or session would be successful in that setting, I immediately thought of “Lucy,” the model of Australopithecus afarensis located in the Human Origins Exhibit at the museum. With my background in philosophy, I continued to approach the idea from a conceptual point of view. I thought about the challenges a clinician might face if Lucy was their patient. Upon looking at the model can anyone really identify the age, race, or sex of this early human ancestor? How would they communicate with her? Would they be able to examine her? What assumptions would they make? And unlike a dated description of a culture from a different location, Lucy would be in the room with the learners and common to everyone.

Only the beginning
Of course, this was only the very beginning. At that time, I had no idea about the complexity and depth of the conversation that was about to ensue. As such, it was to my pleasure to be able to continue by working with and learning from the outstanding faculty from the CMNH and our team, who had the expertise to further unpack this initial concept by covering topics such as how humans evolved yet have a genetic makeup that is 99% similar1,2 and the biocultural construction of race and its implications for diagnosis and health outcomes, as well as to provide just the right patient scenarios to follow through with components of health care disparities and clinical application. In doing so, I feel we have met the goal of delivering a program that takes the learners on a story “through time.” Framing the program around how humans are similar provides the foundation for a new biocultural anthropologic framework that underscores all that we have in common, which then allows us to focus on the “real” things that make our patients unique individuals.


  1. Mersha TB, Abebe T. Self-reported race/ethnicity in the age of genomic research: Its potential impact on understanding health disparities. Hum Genomics. 2015:9:1.
  2. Rotimi CN. Are medical and nonmedical uses of large-scale genomic markers conflating genetics and ‘race’? Nat Genet. 2004;36(11 Suppl):S43–S47.
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Two Sides to Every Coin Tue, 21 Mar 2017 19:23:27 +0000

Editor’s Note: For more about the program described in this blog post, check out this Academic Medicine article in the March 2017 issue and this blog post by another program participant.

By: Anthony O. Cruz, MD

Dr. Cruz is a physician for the Henry Ford Health System. He is passionate about cultural diversity and equity in health care. He is a graduate of Henry Ford’s first Health Equity Scholars Program and applies these skills to his work in the Department of Emergency Medicine.

The Privilege and Responsibility Curricular Exercise gave me a chance to take a good hard look at two very different sides of myself. I come from a mixed background–my mother is Caucasian and my father is Puerto Rican. I grew up in a blue-collar family that struggled to make ends meet, whereas now I have a stable career with financial security. I found these two contrasting identities in stark juxtaposition during this exercise because, depending on my point of view, I can relate to both sides of the dichotomies presented. Someone like me is privileged in a sense, yet I am also part of a minority group. So after reading the statements of privilege I had to first ask myself, “Does this apply to me?” and then ask, “Am I always aware of it when it happens to others?” For example, I’m married to a white woman. I can take her with me anywhere I go and not think twice. She’s an acceptable partner of the opposite sex in the eyes of the world. On the other hand, I can think of a few colleagues with same sex partners. Are they “thinking twice”? Perhaps they avoid going places together because they feel scrutinized. Now let’s take it a step further and think about race. Do others ever look at my wife and think, “Why would she marry somebody who is mixed when she herself is white?”

This activity also pushed me to think harder about how discrimination is woven into our world. It exists on a great many levels even when people remain oblivious to it. It’s an eye-opener, if not a reminder, allowing people to reflect with true empathy on what others who are not exactly like them experience in life. Each and every person is unique and complex. Due to both personal and societal factors, we must open our eyes and become aware of the fact that we are at once bound together and placed at odds with each other through our similarities and differences. Whether it comes to food, language, age, race, religion, sex, color, appearance, money, education, position, gender, sexual orientation, or any of the things that make us who we are, gaining that awareness empowers us. Only then are we able to acknowledge and hopefully dismantle the oppressive aspects of our society that create disparities and that very broadly reinforce the inequities we encounter. Going forward, I’ve learned that it’s not enough to just be a good person and cast no stones. These forces of inequity are real, and we all bear the consequences of allowing them to go unchecked. I am even more dedicated to teaching my children to stand up for diversity and inclusion. I am even more driven to set an example in the ER by actively making all of our patients feel like they belong. The message for my family, friends, students, and co-workers is that it is not OK to just be neutral. In the wise words of Mahatma Gandhi: “Be the change you wish to see in the world.”