Below is the transcript of the following Academic Medicine Podcast episode:
Novel Approaches to Addressing Gender Bias and Structural Racism in Medicine
July 19, 2021
Read more about this episode and listen here.
Toni Gallo:
Hi everyone, I’m Toni Gallo, a staff editor with The Journal and host of the Academic Medicine Podcast. My co-host today is Dr. Monica Lypson, one of The Journal’s associate editors, and we’ll be discussing novel work our three guests have done to address gender and racial bias in medicine.
Toni Gallo:
Dr. Pamela Chen is the author of “The Women Before Me: My Journey Painting Honor Wall Portraits of Women Physicians.” Dr. Jyothi Marbin and Leanna Lewis are the authors of “The Power of Place: Travel to Explore Structural Racism and Health Disparities,” and both articles are available on Academic Medicine right now. Those links will be in the notes for this episode. So I want to start with introductions, Pamela, would you like to start?
Pamela Chen:
Sure. Hi everyone. I’m Pamela Chen. I’m a pediatric resident in the Boston Combined Residency Program in Boston Children’s Hospital and Boston Medical Center.
Jyothi Marbin:
Hi everyone. I’m Jyothi Marbin. I am a general pediatrician. I work at San Francisco General Hospital as a general pediatrician, and I’m also the director of the UC Berkeley-UCSF Joint Medical Program.
Leanna Lewis:
Hi everyone. I’m Leanna Lewis and I use “she/her” pronouns and I am the Associate Director at the UC Berkeley-UCSF Joint Medical Program and I also direct the program for Medical Education for Urban Underserved at JMP, and get to work with GME and primary care at UCSF Benioff Children’s Hospital Oakland.
Monica Lypson:
Hi, I’m Monica Lypson. I’m the Vice Dean of Education for Columbia University Vagelos College of Physicians and Surgeons. Thank you everybody for agreeing to do this.
Toni Gallo:
Thank you all for joining the podcast today. Our discussion is really going to focus on the work that all of our guests have done and why they took the approaches that they did. We’ll talk a little bit about the role of storytelling and getting proximate and addressing bias. Monica, would you like to start our discussion today with a little bit of background for our listeners?
Monica Lypson:
So it is great to read your work. I think every medical school right now is really working towards what they can do to really change the learning environment. And I think your work talks about the learning environment both from the explicit point of view and the implicit point of view. So explicitly meaning antiracism curriculum and more implicit, what is the representation of the pictures on the wall? And how do people feel seen and included in an environment? I’d like to really understand what drew you to not only seeking out the topics of your two papers, but really this idea of why it was important to write about it and disseminate it in a journal like Academic Medicine.
Toni Gallo:
That’s a great lead in to talking about Pamela’s paper. And maybe you can tell us a little bit about what you did and why you decided to take the approach that you do.
Pamela Chen:
Sure. First of all, thank you for inviting me to speak about this and for raising these initiatives to a higher platform. In my paper, I describe a project that I undertook in my fourth year of medical school, to paint an honor wall portrait gallery of our schools’ prominent alumnae of color, and then how that year-long process impacted how I viewed my own place in medicine and academic medicine in particular.
Pamela Chen:
The project started organically, as a series of observations first that the portraits of leaders in medicine that I saw hanging on campus or on our hospital auditorium walls were virtually all White men. And second, that our student body no longer really looked like that. That discrepancy of demographics was partially a sign that some progress has been made in the last few decades but often was a source of tension for myself and for my fellow students of color or fellow female students. The walls are often interpreted by us as this insidious signal that we were imposters, after all. So in trying to identify and interview and paint portraits of the powerful women who had come before me, who had graduated from this school, who had gone on to do amazing things, and then putting their portraits on the walls, I was trying to quite literally make space for us and to remind myself and my fellow women of color, especially, who have passed through these halls before us and that we weren’t alone.
Toni Gallo:
If you check out Pamela’s article on our website, you’ll actually get to see the four portraits that she painted, they’re included and they’re really beautiful. I wonder if you could maybe talk a little bit about why you chose this medium and what was the message that you wanted to send? One of the things you talk about in your paper is that the paintings schools choose to put on the walls really do send a message. And why was it honor wall portraits that you wanted to paint?
Pamela Chen:
Yeah, I think the historical connotation of oil paintings in particular just carries this very unique weight. It’s the media that is chosen to depict royal people or powerful merchants. And it’s the media that is used for traditional honor wall portraits. So all these portraits of Department Chairs and Deans that I had seen. So I wanted to follow in that tradition, but then paint people that unfortunately hadn’t been placed in those positions of prestige or recognition before. So using the same media and then highlighting, “Hey, this is actually the first time that I’m seeing a woman on this wall,” or “This is the first time that I am seeing any other race besides White on this wall,” just to highlight that discrepancy.
Monica Lypson:
I want to tell everybody in the audience to please take the time to look at the visual art, because not only is the depiction of what it means to be included there, but you’re just a beautiful artist and that should be appreciated all in of itself. Can you briefly tell us, for our other two authors, about the curriculum you described, the trip that you have organized for the residents and the faculty, and what really took you to think about a trip to the South and the principles and the pedagogy behind that organizational structure?
Jyothi Marbin:
Yeah, absolutely. Thank you for having us on the podcast. It’s really exciting to be able to talk about the work and Pamela, really nice to meet you and hear about the great work that you’ve been doing as well.
Pamela Chen:
Thank you.
Jyothi Marbin:
You’re welcome. This is a trip that we organized back in 2019, and it was really prompted by a desire to better help learners and honestly, better help faculty also really understand the root causes around health disparities. And this trip was really motivated based on the framework that Dr. Camara Jones has offered us and thinking about racism and the levels of racism in her seminal work from the year 2000 called The Gardener’s Tale. And Dr. Jones talks about racism that occurs on a few different levels–on the internalized level, the personally mediated level, and then the structural level. And in my experience of medical education and graduate medical education, we do spend time talking about interpersonal racism, and we spend time talking about internalized racism and implicit associations. However, we don’t spend a lot of time acknowledging, recognizing, and thinking about structural racism and structures of oppression.
Jyothi Marbin:
We are definitely doing that more now, but back when Leanna and I and others were planning this trip, talking about structural racism was not something that was regularly integrated into the curriculum in graduate medical education. And we particularly wanted to make sure that we were naming anti-Black racism and looking at the legacy of structural racism and how it still continues to impact the health of people living in this country today. And so we thought, how might we create a core learning experience for our residents? And again, also for our faculty, that really centered around the idea of understanding structural racism and health disparities. In addition, obviously to reading and listening to talks, there are other ways obviously to learn. And for me personally, one of the ways that I’ve learned about structural racism and health disparities, and actually also about resilience and leadership, has been through studying the Civil Rights Movement and actually myself in traveling and going to museums.
Jyothi Marbin:
And so we had this crazy idea, which was what if we could actually bring some folks from our residency program to the American South to spend some time immersed in learning and community learning together about the history of our country and the history of structural racism in our country. And also importantly, I think studying, as I said, those stories of resistance and resilience in The Civil Rights Movement and thinking about what are some of the lessons that we can learn from these incredible social justice leaders. And so we use, they’re actually some great frameworks that support the use of travel in learning. I think many of us are probably familiar with Kolb’s Experiential Learning Theory, which definitely applied here, the idea of learning and reflecting. We also leaned on Sociocultural Learning Theory because we were traveling with a group of residents and faculty who knew each other relatively well.
Jyothi Marbin:
It was a diverse group of people who had been working together, many of us, for a few years. And then there’s actually a body of knowledge around transformative travel as well, such that we know that being in a different place actually makes us think and perceive differently. And so keeping all of those things in mind, we thought if we could plan a trip for residents and faculty, really with the purpose of exploring the historical underpinnings of structural racism in order to help us better understand structural racism and how it impacts health disparities that we see here in the Bay Area. And I want to be really clear that we don’t have to travel to see the impact of structural racism. All of us can see the impact of structural racism wherever we are, because structural racism is pervasive, and the health disparities that results from structural racism are pervasive, but we thought that it would be an incredible opportunity for us to do some learning together in community with each other, really focusing and spending some intentional time looking at structural racism and health disparities.
Monica Lypson:
I think your point is well taken, right? That you don’t have to go far and you didn’t, right? You just went to visit another part of this beloved country of ours and to go see that. And I think that’s important for us to even think about it, if it’s the other side of the city. One of the other things that was prevalent in your paper, and you talk a bit about is the concept of cultural humility and how that might play into the experience for the participants, both while they were there but also upon returning. So could you tell us what cultural humility is for those who might not be familiar with the concept? And then tell us a little bit about how that might have played out for the participants, specifically the residents and the faculty upon return.
Leanna Lewis:
I’m excited and delighted to tell any listeners who aren’t familiar with cultural humility a little more about what it is and how it came up and influenced our work. I mean, it’s a framework that’s coined by Drs. Melanie Tervalon and Jann Murray-García in 1998. They both were here in the Bay Area and, at the time of writing that seminal paper, practicing at Children’s Hospital Oakland. And cultural humility is made up of four tenets. One is a lifelong process of critical self-reflection and self-critique. It includes exploring and looking at redressing the power imbalances that so often come up in lots of situations, but certainly in health care and in our patient-provider dynamic and I think in many of the hierarchical dynamics that show up in our health care teams. It also includes developing mutually beneficial partnerships with communities on behalf of the individuals and the populations that we have the privilege of serving. And then lastly, it includes advocating and maintaining institutional accountability that parallels all the other three tenants.
Leanna Lewis:
And so for us, cultural humility is one of the foundational concepts for the curriculum that we provide to the residents. And as part of the curricular program that they receive, just our regular program. And this is what Dr. Marbin is making reference to, the trip was an enhancement of the curriculum that we provide, and a way to offer our residents and our learners a chance to go deeper into a curriculum that we provide.
Leanna Lewis:
And so our participants were well-versed in cultural humility before they went, the tenants of critical self-reflection and lifelong learning came up time and again throughout the trip for so many of our participants, our residents, and our faculty on that trip. Everything we thought we knew and understood about ourselves and our proximity to structural racism was examined and re-examined. Each location and destination, right, experiencing what we had perhaps in many of us had understood and studied theoretically with some distance really was incredibly different once you were immersed in that setting and really walking along the roads and traveling to some of the places and spaces in which we may have had a cursory understanding of that history, but being immersed really invited us to consider our positionality as it relates to structural racism in a very different way, both personally, professionally, and in so many dynamics and so many parts of our lives.
Leanna Lewis:
And I will say, after the trip, many, many of our participants really, right, the continuing lifelong learning and critical self-reflection doesn’t stop. But I’ll say the fourth tenant of advocating and maintaining institutional accountability that paralleled the other principals, our learners and our participants, they doubled down. It just exploded and exponentially we found that their ability to identify structural racism as it was showing up in our work and in our settings, the ability to name it both the fortitude to speak even when our voice shakes. Participants time and again talked about how having walked that path and really understanding themselves in a different way as it related to their, and into our proximity to racism and structural racism, continue to grow. And you can’t unsee what you’ve seen and that showed up. I think it’s hard to articulate the depths to which that showed up once we were back in the Bay Area and back at home.
Toni Gallo:
I think this next question connects to what you were just saying, and this is for all of you. So I’m hoping you can all answer, but this concept of getting proximate, I think that’s Bryan Stevenson’s language of, whether it’s Pamela, the portrait subjects you were painting, or Leanna, as you were just talking about being in these places with people who experienced the things that you were talking about. Could you talk a little bit about the role that played in the work that you were doing, maybe the effect it had on you, specifically? Leanna, maybe you can start and then we’ll go around?
Leanna Lewis:
Yeah, I think one of the things that certainly happened for me as a participant, as well as someone who had designed and was part of working with Dr. Marbin to design the travel experience, again, being so proximate also provided an opportunity for me to see myself in the history and to contextualize, and also then see myself in the resilience that the history requires. And so I think that proximity for me and what we heard from a lot of the participants, again, this exponential growth, right? There’s this saying that I grew up with, right, “To whom much is given, much is required.” Having been in that space and place and hearing again, of what folks had been through and what they’re continuing to survive in spite of, really made, certainly for me, my work and my work towards racial health equity, right.
Leanna Lewis:
It pulled it into a different way, right? You can’t stay, I couldn’t do that trip and experience it and stay distant to it and both to the pain, but especially the resilience, right? Especially all that was pulled and required for us about the extraordinary things that individuals can do. And the ways in which structural racism requires us to both get proximate, but also to then continue to really push forward for something else. I mean, it was life changing. I really can never be the same after that trip. And I’m saying that as someone who has spent my life’s work doing this, designed it right? Thought I knew a lot and walking that path really shifted things. I mean, Bryan Stevenson is right about proximity.
Pamela Chen:
I think, for me, I was just so fortunate to get to interview my portrait subjects before I painted them. And going into the project, I knew that I wanted to paint living subjects so that I could actually meet them and talk to them and understand their story. I was so, so lucky to get to meet and interview Dr. Raquel Cohen before she passed away last year, as she was one of the first women to actually attend Harvard Medical School in the class of 1949. So the absolute first co-educational class and hearing that experience was incredible. And then, similarly getting to interview Dean Higginbotham, who desegregated her school when she was younger and understanding how those experiences aren’t just some distant history but are very close current experiences of real, living people. And that’s why we aren’t seeing tons of women on the walls, is because they hadn’t been admitted since 1945. And that’s only a handful of decades that’s still within living history.
Pamela Chen:
I think really understanding that, and then interviewing the other subjects as well and hearing how there are so many continued themes of how they had been overlooked because of their race or because of their gender, passed over for promotions, not taken seriously. They had their motherhood called into question for how dedicated they would be to their work. And Dr. Lee talked about how, when she was interviewing for surgery residencies, the program directors would explicitly say, “Hey, you’re a woman. Why would I choose you over a man when you’re probably going to get pregnant during the next five years and have to take time off from the program?” So these are all experiences of people within living history and understanding that really validated all the things that I was seeing around me. And then of course, just getting to know their stories, having them feel invested in me as well, having them mentor me was just so powerful.
Pamela Chen:
They talked about obviously their hardships, but then also their sources of joy and purpose and how they really connected with their patients of color or with other underserved patients in a way that other people couldn’t, just once they walked into the room being able to build that rapport so much more easily. So that really spurred me to think about my own career path and being more aspirational in my 20-year plans, and my lofty, lofty career plans, knowing that there are people who had done it before me, who had gone through similar microaggressions and then even obviously, macro-aggressions and very overt structural racism and sexism.
Monica Lypson:
I think your stories and your interviewing highlights this idea about why stories are important and just starting with you, Pam, and then opening to others, because I think even at the trip, walking in the footsteps, we heard a lot about stories. Can you tell me why storytelling is powerful in both of your work and why it was highlighted as part of that?
Pamela Chen:
Yeah, I think storytelling is just a way of making these abstract concepts a lot more tangible. I think if someone’s not even aware of a certain privilege they possessed or a bias they hold, it’s really hard to just lecture them on this concept. But by directly comparing and contrasting lived experiences, it’s a way to naturally elicit human empathy. This is different, I’m thinking about how as a hearing person, I don’t think about that privilege very often, but one of my co-residents who is deaf pointed out to us, “Hey, can we please wear these clear face masks because actually not being able to lip read has made my experience in residency really, really hard.” So it’s by telling these stories I think we can highlight these moments that otherwise get overlooked.
Jyothi Marbin:
I would add, that was beautifully said Pamela, I would add, I think stories connect us as human beings and they help us each find meaning. And I love what you said, Leanna, that being on that trip, you can’t unsee what you’ve seen and you can’t, it’s not a word, but you can’t unfeel what you feel when you’re there. Those feelings and those stories stay with you and storytelling is actually a technique of critical pedagogy, which is what we use as one of the frameworks on the trip.
Jyothi Marbin:
I think one of the things that Leanna has actually taught me are some concepts around the idea of the danger of a single story, and really, stories are such a powerful tool for teaching and for sharing knowledge. And we also have to be really careful, because sometimes we can transmit, if we just depend on one story, that can be the way that we see the world and we can transmit bias through just depending on a single story. So I think one of the other lessons that emerged from us was really around who’s telling the story? Who has the privilege of telling the story? And really listening with great humility and also listening with a critical ear just to be sure that you’re hearing all sides of the story and not just maybe the dominant narrative that is told.
Leanna Lewis:
I would add that the storytelling, one of the maybe surprises in our trip, was also the roles of both the stories and our understanding of the stories as they came about, but also the cultivation of ourselves within the stories. And so for our trip and for our participants, especially for our Black Indigenous People of Color participants and our Black learners and faculty on this trip, it was really important to have a space to hear and understand and relate to the stories of historical and contemporary racism while cultivating our own stories in a protected space. And so wed use racial affinity groups and race-based caucusing, as we termed it, during the trip to allow our Black participants the space to really process and understand the stories, as well as to cultivate their own stories outside of, as Toni Morrison references, a White gaze, right?
Leanna Lewis:
The opportunity to really integrate the learning while creating another space because there’s this toll that the work of both intellectually and theoretically understanding the historical underpinnings of structural racism in the US, for those of us who also experience anti-Black racism, it’s just daunting right? It’s a big, old task, but also when we allow that unfiltered space in that protected space, what we’ve found is that both the understanding of the stories, but also our learners and our participants’ ability to contextualize their own stories, right, really got to flourish.
Leanna Lewis:
And I truly believe that’s why we saw what we saw after the trip, right? People could stand forward and they could come and lean forward in a different way because their story was also right. Again, this thing of proximity, right? They were in the story and they had the space to see themselves within the stories and their relationship to the stories that we heard and how we understood that.
Monica Lypson:
I think you both have really talked about this idea of there’s transformational learning, right? The idea about being proximate, the concept of social, cultural learning, and really exposing those pedagogies to medical education should be applauded. I guess, what final thoughts do you all have about your work and what would you like the audience to know in these last few minutes?
Jyothi Marbin:
I would say that in medicine we have failed on many levels to actually recognize, acknowledge, and address structural racism. And I think that’s on us, those of us who are in academic medicine, we need to figure out what our racial reckoning looks like. And part of that, I think, is being open to new ways of teaching and new ways of learning. And I think what both Pamela have described and what Leanna and I have described are maybe not traditional approaches that we might use in medical education. But I think in order for us to think deeply and seriously, and actually start to dismantle some of the structures of oppression and really address the structural racism that leads to the health disparities that we see in our community and in our population, we do need to be open to different methods, different ways of teaching, learning, and working with our learners. And I think also recognizing that our learners encompasses both faculty and trainees at all levels.
Leanna Lewis:
I hope medicine and medical education is willing to design and center at the margins, right. To really reconsider what we do and how we do it and who it’s designed for. And I’d love to see, and I hope we do more of creating both opportunities that center those learners, but also creating the space for those learners in using racial affinity groups in using those kind of places where we get a chance for the kind of unfiltered learning that I think BIPOC folks need in order to help medicine reach its potential, right? Get to its place where it says it wants to be and really to dismantle structural racism. So I hope we’re brave and innovative and we do more of that and there’s more willingness to center folks who look like the folks in Dr. Chen’s portraits.
Pamela Chen:
Yeah. I definitely agree. And one of the reasons why I decided to have my portraits hang in our student center is because I wanted a student of color or a female student, to look up from her notes at a portrait of a doctor who looked like her and think, “Hey, I could be a Dean someday, too.” I think I do want to reiterate though, that I do feel like, as a visual artist, this was my method of advocacy. It was something that was therapeutic for myself, but it really should be viewed as just the beginning of diversity and inclusion efforts and efforts against racism and sexism. I think lifting up the stories of these women and the images of these particular women obviously needs to be accompanied by work, by the work to reduce all forms of sexism in our institutions, and to really think about our recruitment, and retention, and promotion pipelines and how we can actually get more diverse people in more positions of leadership.
Jyothi Marbin:
Sorry, Toni, can I just add one more thing?
Toni Gallo:
Yes.
Jyothi Marbin:
I think another theme that came up on our trip that we write about in the paper, but I just want to say out loud is that as we’re doing this type of work and learning, particularly around structural racism and anti-Black racism, we just need to be really careful that we’re not exploiting Black pain in order to dismantle racism. I think as we’re thinking about being proximate and hearing stories, there can be a tendency to, or often what might be a well-intentioned… something that happens in which Black pain and the pain of people who have suffered for generations to be exploited. And so I think that’s really important that we’re again approaching, as Leanna said, with the deepest humility and deepest understanding of that.
Toni Gallo:
Thank you all for joining the podcast today. And I want to encourage our listeners to visit academicmedicine.org to find the articles that we discussed today. And I hope you’ll really think about the programs that we talked about and send us your work on novel programs that you have for overcoming bias and addressing structural racism. We’d love to hear about the work that you’re doing. On our website, you can find our complete archive dating back to 1926, and you can access additional content like free eBooks and article collections. Be sure to subscribe to Academic Medicine through the subscriptions link under the Journal Info tab or visit shop.lww.com and enter Academic Medicine in the search bar. You can check out our blog, AM Rounds, at academicmedicineblog.org, follow us and interact with the journal staff on Twitter @AcadMedJournal, and subscribe to this podcast through Apple Podcasts, Spotify, or wherever else you get your podcasts. While you’re there, please leave us a rating and a review and let us know how we’re doing. Thanks so much for listening.
