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ANNOUNCER:
Welcome to ASA’s Central Line, the official podcast of the American Society of Anesthesiologists, edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome to another episode of Central Line. I'm your host, Dr. Adam Striker. Today, I'm joined by Dr. Crystal Wright, Chair of ASA's Committee on Professional Diversity and Associate Professor in the Department of Anesthesiology and Perioperative Medicine at the University of Texas MD Anderson Cancer Center. Today, we're going to dig into the important topics of inclusion, gender and diversity. Dr. Wright, welcome to the show.
DR. CRYSTAL WRIGHT:
Thank you Dr. Striker, it’s great for me to be here this evening with you.
DR. STRIKER:
Well, let's start with your current role in the American Society of Anesthesiologists. You're the chair of the ASA Committee on Professional Diversity. Tell us a little bit about your role in that committee and the significant work the committee performs, especially as it comes to, uh, promoting diversity and inclusion.
DR. WRIGHT:
Well, the ASA and the Committee on Professional Diversity has done a remarkable job in carrying out its mission to promote diversity within the ASA. For starters, we have the ASA Mentoring Program, which has grown over the past several years. The Mentoring Program is an opportunity for an ASA member to mentor a mentee in terms of allowing them to understand and to develop in a relationship with a mentor that is an active member within the ASA through a research program. And the research program focuses on topics that are related to diversity as well as includes mentors and mentees from different backgrounds. So that's one of the ways within our committee that we look to promote diversity and inclusion within the Committee on Professional Diversity.
In order to improve the pipeline of those that are interested in moving forward in the specialty of medicine, we are involved with the AMA Doctors Back to School Program. And that has been an initiative since 2016 that was started by an ASA member, Dr. Vernon Ross, and, um, members of our committee are a part of that AMA Doctors Back to School Program.
The Committee on Professional Diversity has also worked with the ASA in terms of advocacy and looking at health disparities and how we as members within the Committee can, can help to mitigate some of those health disparities associated with diverse populations.
In addition, the Committee on Professional Diversity has most recently done an ASA round table conversation and this was a round table conversation just to hear from members of Committees on the Professional Diversity as well as the Women in Anesthesia Committee in order to allow us to come together and to have conversations about how we are trying to promote diversity and inclusion within the ASA.
DR. STRIKER:
Certainly sounds like there's a lot of significant work that the committee performs and probably more than people realized. How has this particular role impacted your career?
DR. WRIGHT:
Well, you know, my involvement with the ASA started out as a resident member, and I encourage all residents to take the opportunity to get involved within the ASA because it is truly is a lifelong, I guess relationship, that you can begin to develop as part of your career. And through that involvement with the ASA, I’ve have had the opportunity to participate in organized medicine both at the State and National level and fully engage in an area of medicine that has brought me a significant amount of fulfillment and engaging in advocacy related efforts that has helped to promote the safety and quality for our patients. And that has been an ex, inspiring experience for me.
And in addition, that involvement has also taught me the importance of being a physician and being a physician that is involved in the diagnosis, management and treatment of patients, but has also qualified for me the other intangible qualities that I think are so important for a physician to embody and has allowed me just to kind of gain that, that empathy and awareness of the collective aspects of life I think that, that affect medicine. And I, you know, just I've had so many mentors within both my State Society of Texas as well as within the ASA that have afforded me those opportunities. And when I look at the Committee on Professional Diversity, I am, you know, grateful for the growth that the Committee has had over the past several years.
DR. STRIKER:
Well, you mention mentors. That's certainly a theme that we've tried to underscore throughout the series, whether we talk about healthcare leadership or we’ve talked to physician scientists, how, the importance of having a mentor and the importance of if you're given the opportunity to act as a mentor and truly the importance that role plays in cultivating future leaders in the Society, and professional development in general. I, I would think you would agree that that importance cannot be overstated.
DR. WRIGHT:
Absolutely. You know, the promotion, or the support, or the sponsorship of individuals, it's so important and not only is that important for early career physicians, but it's so important I think as physicians kind of get started in practice, whether it's in a private practice or where, or rather it’s in an academic practice and then they kind of get in that I would say, five to seven year span of practice and they're looking for mentors, they're looking for sponsorship, they're looking for people to sponsor them, to promote them and help them to figure out what it is that is important for them to become involved in and to become an active part in where they can make an impact. And part of making that impact as you mentioned is that it's so important for mentors to help emerging physicians recognize where they can make their impact.
DR. STRIKER:
Well, let’s talk a little bit about unconscious bias. The ASA has promoted awareness on this topic, and why don't you tell us a little bit about the steps taken by the ASA?
DR. WRIGHT:
Sure, you know, the ASA has taken many steps to promote the awareness of unconscious bias. The ASA Mentoring Program as I talked about a little bit before has been one component. That program has brought some awareness of unconscious bias through trainees that perform research related to unconscious bias. And several recipients of the ASA Mentoring Program Grant have conducted their research projects that have been related to unconscious bias. So, that's one way that the ASA is putting funding to bring awareness about unconscious bias.
You know, in their CME meetings, the, the ASA always strives to include some topics that are related to unconscious bias and specifically at the 2020 Practice Management Meeting this, uh, this past January, we had a three panelist presentation that I moderated that was a topic that was entitled Confronting Your Unconscious Bias and Embracing Gender Diversity and how that’s smart practice management. We had Dr. Laura Dew, who is a private practice anesthesiologist that talked about unconscious gender bias. Dr. Tom Rouse who talked about addressing gender bias at the departmental level, and we had Dr. Harriet Hopf who talked about why diversity provides a competitive advantage to your organization.
And so that panel conversation was very well received. We had large attendance in that, at that panel conversation. And I think that's when the ASA continues to promote topics at different meetings that deal with unconscious bias, that is a step in the right direction to bring awareness to the issue of, of unconscious bias.
DR STRIKER:
Well, let's talk about some specifics here. What are some ways we can all become more aware of our unconscious biases? We all have them, I think we’d all recognize that, but how do we work to excavate them?
DR. WRIGHT:
You know, I think when we think about unconscious biases, you know we have to think about what they are and put them into perspective of how we define them. And unconscious biases, you know, as we know are these social stereotypes about certain groups of people that individuals form outside of their own conscious awareness. As you mentioned, everyone holds those unconscious beliefs about certain groups and how they tend to organize the social world in their, you know, in their own mind.
And strategies, I think to address unconscious bias has to occur at two different levels. We need to look at you know, how are we as an individual recognizing our unconscious bias? And at an institutional level, what are we doing to mitigate those unconscious biases? And I think when we look at, from the individual perspective, the most powerful tool is awareness and being aware of the fact that you possess unconscious bias and looking to educate yourself on how to eradicate or mitigate those unconscious biases.
And I think the other part of when we look at organizations, you know, I think that it's important to incorporate methods to minimize those influences of unconscious bias in the life cycle of employment from the beginning, at the recruitment stage, throughout the evaluation and retention process, until the completion of an employee's life cycle. And so I think that it's important for leaders of institutions to put things in place. As for example, there's one institution that part of their faculty recruitment process includes a recruitment process that minimizes bias while at the same time leveraging diversity. And I think it's important for institutions to look for different methods to do that at all stages as I mentioned in the life cycle of an employee.
DR STRIKER:
Do you think that we all possess unconscious biases, but is that something we all have to learn to compensate for in some fashion at all times, or is that something you can strive to get rid of, theoretically?
DR. WRIGHT:
I think it's a journey. And I think it's a journey for all of us. I think that these conversations about unconscious bias, that is the start along the journey. When we look at eradicating them, I, I don't know if we can eradicate anything, but I think that it's a journey and I think that as we become vulnerable to become more aware of our unconscious biases, I think that we can move further along as individuals along that journey.
DR STRIKER:
Well, one of the places we certainly see this play out is, um, when we talk about compensation and gender inequities. In 2019 an ASA survey found that women are compensated less than men in aggregate, both in private practice and academics. Do you get a sense that this is improving at all?
DR. WRIGHT:
So where we are right now, I, and we have to take into consideration, you know, where we are with this global COVID-19 pandemic. Medicine is at a crisis point. Healthcare professionals are responding with an astounding display of selflessness and caring for patients despite the risk of personal harm for themselves and our efforts are applauded but the global spread of this has caused sudden and dramatic societal changes. In the COVID-19 pandemic it ties in with what we're looking at in some of these gender inequities. The COVID-19 pandemic has created sudden stressors across many domains of our lives and an already stressed medical system. Um, you know, prior to the COVID-19 pandemic physician burnout was already at its peak. And while we're seeing physician effects of burnout increase during the COVID-19 pandemic, we can be certain that the stressors and the recovery in post COVID-19 will also be increased.
And as the system of medicine continues to be stressed, women are going to continue to be in a disadvantaged position as they are the ones that, in general, are the ones in a household unit that have multiple responsibilities that fall upon them. And so the lack of support provided to female physicians during these critical times are managing the many different aspects of life including child care, elder care, home school, while at the same time managing their academic or private practices, will continue to widen that compensation gap for women. So as I look forward for women, there's something to be a little concerned about because universal options are not in place to support women so that they can handle the many tasks that they are often called upon to do in times of crisis.
And I don't by any means mean to mitigate this struggle for men because this struggle occurs for men as well. But many situations are amongst women who were already, as we talked about in the question, at an established decreased level of compensation. You know, at the height of the pandemic, a hospital in Texas understood the situation and provided childcare and hired six full-time teachers to be on site to be available for assistance of remote learning for children. So this is an example of providing a systemic structure so that physicians can continue to practice medicine in their established roll without conflict. And so implementation of these systemic practices is what allows for physicians, and females in particular, to continue practicing medicine to their fullest capabilities. And so I think once we can recognize that we can assist women in their professional goals then we can start to be hopeful about mitigating the compensation gap.
DR. STRIKER:
Actually, at our institution this came up recently trying to provide some solid infrastructure to help with, you know, workers throughout the healthcare system that are going to need assistance as the school year starts, and more and more institutions are going to purely online learning and the recognition that to have your workforce available, you're going to need to, um, provide some kind of solution in that regard. So I think, probably more institutions are going to be thinking along those lines of, of the one you mentioned already in Texas. Um, but what can we specifically do as anesthesiologists, to ensure progress on, on this specific front?
DR. WRIGHT:
I think recognizing that, I know several leaders within the ASA are looking at how we can bring this information to the ASA at an organizational level, because it is a nationwide issue. I think that there are several opportunities for academic practices and people in certain academic practices to recognize, for example, when you look at promotion if you're at an academic practice that's related to your productivity, right? And I know some, some institutions are looking at stopping the promotion clock at this point recognizing that women physicians, and women anesthesiologists that are in academic practices or that are in leadership roles or that are trying to be in leadership roles in private practice groups that the efforts put forth for some may be less at this point, but it's not a reflection of their capabilities or reflection of what their goals are. It's just something they’re recognizing the conflict at the time. And I think as more groups start to do that, I think that's going to help to, again, bringing in some systemic practices to help to mitigate the long-term effect of that.
DR. STRIKER:
I get the sense that a lot of people, they may say that they recognize the reality of unconscious biases, and that, and that we all have them. Are there people out there that may say, you know what, I don't have a problem. I don't have to worry but they still may be engaging in these, in these behaviors or creating a, an environment where the bias does exist and they're not recognizing it? Are there steps that they should take proactively, even if they think they don't need to?
DR. WRIGHT:
Well there, there is an implicit association test, and anyone can take that. You can take it online. And so I think that I would challenge anyone to consider looking at objective tools because there, there are objective tools out there that can help you identify where your unconscious bias may lie. And I think that as people look at it from a more objective standpoint that they will see where they may be surprised at how their thoughts could be perceived as unconscious bias.
DR. STRIKER:
I'm sure all institutions probably mandate a certain, you know, a set of curricula that you know, everyone has to take and that address these things, but I often time feel that these things are dismissed so easily because, ah, it’s a required thing I have to do. Fine, I'll just do it. But perhaps certain leaders should go the extra step to seek out a, a tool that you suggest that, that really may be helpful.
DR. WRIGHT:
Right, and I think that's part of that journey, right? It think that’s part of the journey that we talked about earlier where the expectation is not for everyone to be on the same part of the journey at the same time. What we should be striving for is for people to be on their own journey. And that's going to look different for different people. And I think leaders of institutions, and leaders of organizations, I think that their role is to ensure that people that they lead are on their own journey in right, in become self-aware.
DR. STRIKER:
Well, let's turn to patient care now. What are some areas that anesthesiologists can work in to reduce health disparities in the country?
DR. WRIGHT:
Right, this is a, a topic that has been very near and dear to me more recently and we've had several conversations, you know, with our Committee about how we can bring both the work of our Committee and the work of the ASA to, in add, you know, in addition to what we look for in terms of mitigating health disparities. As the perioperative physicians that we are, we have a critical role in ensuring that access to quality care is available to all patients. Um, and, you know, while we are involved in critical aspects of patient care, we do play some important role of social determinants of health. And some key areas where we can be a value in this area include, you know, ensuring that all patients, regardless of their location of care should have access to physician-lead care.
Anesthesia care is a very high-risk medical service. Our risks increase for patients with pre-existing health conditions such as diabetes, heart disease, high blood pressure. We all know that. Um, and these conditions have some prevalence in Black and Latino communities. And high patient safety and better health outcomes is an imperative for patients with pre-existing health conditions, and that patient population with those health disparities occur, some hospitals provide anesthesia services without physician involvement. And it's important that we advocate for these patients that regardless of where they are receiving their care that they can have access to physician-led models of anesthesia care delivery.
Um, you know another important advocacy area for anesthesiologists is as we look at preoperative anesthesia assessment. Certain populations, and the Black community are more likely to suffer as we know from, as I mentioned earlier, from chronic conditions and suffer from multiple conditions with significant implications for their life and, and also for their perioperative time period. And often times if they're coming in for a surgery, an anesthesiologist may be the first time that someone has seen a physician. And it's important for that to be recognized as, as the start of care for some of our patients. And so those are some of the ways I think that we can look to, kind of mitigate and start to advocate for our patients in terms of healthcare disparities.
DR. STRIKER:
Those are great points. We've talked before on the podcast about anesthesiologists engaged in pre-operative assessments and, and how that assessment can certainly be used in a number of ways to the better the overall health of the patient.
DR. WRIGHT:
Absolutely.
DR. STRIKER:
…um, and whether it's questions or suggestions about um, health behaviors. But the other point which I don't think we've talked about specifically in this context before about, you know, physician-led care in communities where, that may not have access to it. Um, anesthesia is a nebulous field to so many and it’s really an opportunity for us to, to play a proactive role because so many people wouldn't even know probably that that would be something that they should have access to. And, you know, they might show up in an institution and its provided in such a way that nobody would know that it, it should be done in a different way, or could be done in different way. And so that that first point is especially helpful, I think as well.
DR. WRIGHT:
And it's important that, you know, we get that message out to the population that they should have access to physician-led anesthesia care.
DR. STRIKER:
Right, I agree. I feel, you know, often times we, as a society, settle much too often for, you know, lesser degrees of care in certain areas. You know, we always try to tow the line between access to care and the highest level of acuity that we can provide, and I, I feel like there’re certainly times where we need to, uh, have certain areas have access to care. But I feel like often times we make a sacrifice on the level of care and the acuity just to be able to say we, that access is provided, when we know that we could really be doing a better job.
DR. WRIGHT:
Better job, right, right.
DR. STRIKER:
Well, let’s talk about clinical trials. How important is it to have diversity in research?
DR. WRIGHT:
Yes, it's important to, as we look at diversity and you know in research from uh, variations in representation by different racial groups, as well as, you know with gender, and traditionally, you know, pharmaceutical research has relied on representation by Caucasian patients and then under-representation by Blacks, Latinos and other minorities. And what's been well documented is that there are variations in drug effectiveness and safety among racial groups. And, you know, it's important that these disparities be addressed when looking for grant reviews and product approvals. Um, you know, FAER, I think has done some research to stress the importance of diversity and inclusion in the development of anesthesiology researchers and assuring diversity and study population. And this is important, you know, as we look for the effects of different drug therapies on different patient populations. And we want to ensure that we're being in, inclusive, you know, in these research and clinical trials.
DR. STRIKER:
Is gender disparity a problem on this front?
DR. WRIGHT:
Absolutely. You know, the evidence basis of medicine, some of it is flawed because there is not a reassurance that gender differences are included in study design and in, and in analysis. And so, you know, guidelines based on one gender maybe developed and prescribed, you know, to both, um, but that is not necessarily the outcomes and the reactions for certain drugs can be different in different genders. And so it's important for, you know, researchers to address some of the barriers that can discourage different genders and women from participating, you know, in different clinical trials.
DR. STRIKER:
Do you think the medical community is more comfortable talking about the social determinants of health for marginalized people collectively rather than discussing how we might discriminate against actual patients in our care?
DR. WRIGHT:
You know, racial discrimination occurs on many levels and in a variety of different contexts, right, intertwined with income, education level, and you know, all these other socio demographic factors. It can be subtle or it can be obvious. I recently took care of a patient in pre-op and asked her about her pain tolerance and you know afterwards I noticed her disposition completely changed after asking her that question, and I asked her why her disposition had changed and she began to talk about a recent experience to me and that she had gone to another ER for a painful medical condition and she tells the story of how her pain level wasn’t necessarily recognized by the outside ER physician. They kept ignoring and attributing her pain, you know, to something else and she felt as though the doctor thought she was trying to get pain medicine and was trying to dismiss her symptoms. Um, and you know, she was convinced that she was being treated poorly because she was a Black female.
You know, as physicians, we take an oath to treat all patients equally and yet not all patients are treated equally and the answer to that why is rather complicated because physicians, we know that we can understand some of the social determinants of health because we know that it exists. But I don't believe the awareness of discrimination by physicians is fundamentally a part of the awareness pattern because we're just not trained that way. Um, medical education is about treating everyone equally and providing equal care to all patients, but medical students and trainees come to medical school with their own biases, and that's where I think the discrimination in treatment often takes place.
DR. STRIKER:
Well, it's a great point. I guess I would ask a similar question which we talked about earlier, which is do we seek out objective tools to try to make us all better in that regard? How do we get better? How do we, how do we recognize as you pointed out, this is a long journey, and a career journey, probably for all of us. How do we take active steps to make sure we're addressing that and we don't fall into the trap of always succumbing to these biases?
DR. WRIGHT:
Right. And I think it's important, again, for that self-awareness, for us to recognize where we are as, as individuals along the journey. And you know being vulnerable to being corrected and I think once we have that vulnerability of being corrected, I think that, it, that can be a powerful tool to moving us forward along the journey of becoming self-aware.
DR. STRIKER:
And do you think these continual conversation, both on this level and yet locally where each of us practices, those continual conversation lead to that awareness?
DR. WRIGHT:
Absolutely. You know, I think that fundamentally having these conversations with our colleagues, with our friend groups, that are of diverse backgrounds, I think that that enlightenment will allow people to have that self-awareness. There is so much that I think can be gained just because we've gotten to the point where we are comfortable having these conversations. I think not having these conversations is not the answer. But as we become very comfortable about talking about it and talking about unconscious bias and talking about social determinants of health, and talking about, you know, health disparities and talking about all of these other factors and demographic factors because if we become comfortable talking about that, I think as we include that in medical education as part of conversation, I think that that is going to bring us to a place where we want to be.
DR. STRIKER:
Well, I was wondering if you had received any key advice early in your career from a mentor and if so, or if, if in either case, do you have specific advice that you would like to pass on to younger anesthesiologists, and particularly female anesthesiologists, that you can share with our listeners?
DR. WRIGHT:
You know, I have been fortunate to have a plethora of mentors in my life and all of this started with a mother who was bold and relentless in her advice and, and still is. Um, so I, you know, I know that I'm the person that I am because of a strong mother that was very deliberate in raising me and I'm also grateful to the life mentors that have taken the time, you know, to invest in me. Not only did my mentors take time to invest in helping me to make my career and professional decisions, but they also took the time to truly know me, understand me, understand my life circumstances, my desires, my hopes and my struggles, and with their wisdom and an understanding, they were able to provide me with meaningful advice for my life. And, and I continue to be grateful for that.
But one thing that is pivotal when being a mentee, is understanding of what it means to be mentored. And I say this to younger anesthesiologists, male and female, and because I believe the fundamental concept of being mentored is the willingness to listen. The mentor-mentee relationship should happen organically and it should be fostered over time. Again, this is a lifelong relationship that can be beneficial to you. And so my, my best advice, you know, for any young anesthesiologist is that you must be willing to be vulnerable and to let that person into your life and maintain that relationship. I mean, that has served me well and, and, and I guarantee for anyone that is blessed enough to find that type of relationship, it will serve you well if you continue to foster it.
DR. STRIKER:
I couldn't agree more. I, you know, think back to some of the, the most troubling times or the, the toughest time to get through, have I only been able to do it because I've had mentors that have helped me through those and so I, I think that's incredibly well stated.
Well as we close out here, I just wanted to ask, when you think about healthcare and our specialty specifically, along the lines of diversity and inclusion, are you hopeful for what the future holds for us?
DR. WRIGHT:
You know, our specialty has had some remarkable leadership during a time when our country was faced with the reminders of racism and, and health disparities. The leaders of our specialty have long recognized that we can, you know, empower our positions within the organization to thrive. And with, as with all things that requires change and it's one step at a time and our organization has done that for our specialty, and for our physicians. Um, our specialty has engaged in difficult conversations by all minorities, and has expanded initiatives that have addressed inequities for women, for people of all races, and the LGBT community. And so I think the ability of our specialty and the organization to develop programs that are diverse, is the initial step, um, and our specialty is pivoting right at this point, I think, as America is, uh to evaluate how we can be more inclusive and that recent pivot within the organization with, and within our specialty has been authentic and deliberate. And those actions give me hope.
DR. STRIKER:
Excellent. Well, Dr. Wright, thank you so much for joining us today and talking about this incredibly important topic, and I know we're going to continue to discuss diversity and, uh, inclusion over the coming months, and and years, hopefully, so that we can affect some some real positive uh, change in this regard. And so, so I thank you again for joining us, and uh, it's been great talking with you.
DR. WRIGHT:
Thank you Dr. Striker. It's been an absolute honor to be here and have this conversation with you as well. I’d just like to tell your audience that my statements today are, you know, based on, on my personal experiences, uh, within anesthesiology and that these my personal remarks and my personal statements and my personal thoughts on, on where we are as an organization and a specialty. I thank you for the opportunity, and I look, I look forward to having more conversations with you in the future.
DR. STRIKER:
Absolutely. Well, this is Adam Striker, thanking everyone for joining us on another episode of Central Line. Please tune in again next time. Thanks.
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ANNOUNCER:
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