It’s critical to promote a culture of emotional safety in your clinical setting. Offer support and speak up when you witness hurtful incidents.
Lifelong Learning in Clinical Excellence | November 17, 2020 | 4 min read
By Geoff Stetson, MD, UCSF
Scene: ER, bed #2
[Resident physician who identifies as cis-female]: “May I perform an exam, sir?”
[Patient]: “You can examine anything you want, honey.”
Scene : Internal medicine wards, medical team at patient’s bedside for morning rounds
[Attending physician who identifies as cis-female and Indian]: “Can you tell us more about the pain you experienced in your chest?”
Patient turns and proceeds to tell his story directly to the medical student who identifies as white and male.
Scene: Internal medicine wards, medical student enters a patient’s room to interview them.
[Tall medical student who identifies as Black and male]: “Hello Ms. A! My name is B. I’ll be the medical student taking care of you while you’re here.”
[Patient]: “Whoa! You look more like a basketball player than a doctor.”
Above are examples of bias and discrimination I’ve witnessed in the clinical setting. Anyone who’s spent more than a week in a hospital can probably describe similar instances, thus alluding to their pervasiveness. I’m a heterosexual, cis-gender, white, male physician. My personal experience of bias is limited. However, as a teacher in the clinical learning environment, it’s my responsibility to ensure my learners have the psychological safety needed to succeed. That doesn’t mean shielding our students from bias. Rather it means exhibiting allyship and engaging in upstanding.
Allyship: the practice of emphasizing social justice, inclusion, and human rights by members of an ingroup, to advance the interests of an oppressed or marginalized outgroup.
Upstanding: speaking up when being a bystander (one who is present, but not taking part in a situation or event).
Another way to think about these two concepts is allyship is an attitude or set of values we need to internalize and display, and upstanding is putting your allyship into action in the moment.
So, how does one accomplish allyship and upstanding? There are three steps: setting the tone and expectations, building and using a “toolbox,” and debriefing.
1. Set the tone and expectations
This is where you make clear your intentions to be an ally.
A. Explain that acts of bias may occur while your team is working together. Bias may come from patients or family members, or colleagues.
B. Pledge to be an ally. Let it be known that you want to help to make everyone feel safe. Encourage members of the team to be allies for each other.
C. Ask how each team member wants you to upstand. Do they want to defend themselves? Do they want you to take charge? Do they prefer a direct or subtle approach?
D. Discuss lenses and your fallibility. You can only see the world through your own eyes. That means you’ll miss acts of bias. You may even commit acts of bias. Make clear that you’re growing in this area, and you want all the feedback you can get about your performance.
2. Build and use a “toolbox”
Responding in the moment to an act of bias can be difficult and you have to be prepared. It’s critical to think about how you want to respond beforehand and have strategies in your back pocket. My favorite approach is from Dr. Kimberly Manning (@gradydoctor), Professor of Medicine and Associate Vice Chair of Diversity, Equity, and Inclusion at Emory University. She calls it the 5 Ds. The first D you should do every time. The other four are options for how to further respond.
A. Display Discomfort: Use body language to show you noticed something wrong or inappropriate. Furrow your brow. Frown. Shake your head. Do anything, EXCEPT pretend like nothing happened.
B. Direct: In the moment, state clearly and firmly that you don’t condone the behavior, for example, “What you just said is not okay.”
C. Distract: For those who are not in supervisory roles, or when interacting with someone with more “power” in traditional hierarchies, a tactic can be to redirect the focus or change the subject to a relevant topic.
D. Delegate: Speak to someone else to discuss appropriate next steps. “Hey, Dr. Stetson, I had an uncomfortable encounter with X. I wanted to hear your thoughts.”
E. Delay: It’s never too late to do the right thing. If you’re thinking about something that went wrong and nothing has been done yet, take time to bring it up. “Hey folks. That thing that happened yesterday with X, I can’t get it out of my head. That made me really uncomfortable. How are you all feeling?”
3. Debrief : Arguably the most important step. It’s rare that the actual upstanding part goes smoothly. The debrief is everyone’s chance to reflect on the moment and support one another. Let everyone know how you felt and ask how others are feeling. This is also a great time to display a growth mindset and get feedback about how you can be a better upstander the next time.
Many institutions are making strides towards improving diversity, equity, and inclusion, including the recruitment of students and residents who identify as belonging to historically underrepresented groups. However, if we aren’t equipped to display allyship and engage in upstanding once they arrive, we will be doing them, our patients, and the future of medicine a grave disservice.