Implicit bias, intentionality in leadership and authenticity in self are among the concepts discussed during the panel discussion at AAPL’s Winter Institute.
Although industry leaders are making admirable progress in their efforts to develop and maintain a diverse and inclusive workplace, many barriers remain. Chief among them is the failure of people to recognize their own biases, regardless of their varied backgrounds. To create the needed awareness requires opening a door to uncomfortable conversations, experts say.
The American Association for Physician Leadership took a step in that direction by hosting a discussion on diversity and inclusion at its 2019 Winter Institute in St. Petersburg, Florida, on Jan. 28. A ballroom full of physicians and physician leaders attended, and many interacted with the three panelists:
- Pamela Schwartz, DO, an OB-GYN in Lakeland, Florida, provided an overview of her three-decade journey in health care as an African-American woman and the biases she faced.
- Marissa Levine, MD, joined the University of South Florida in Tampa as a professor of population health in August 2018 after four years as Virginia’s state health commissioner. As a transgender woman who transitioned 13 years ago, she advocates for compassion and support for others in the pursuit of their authenticity.
- Larry Perkins, PhD, associate vice president for talent and diversity at the University of Texas MD Anderson Cancer Center in Houston, has seen firsthand the importance of creating a structured diversity policy and leadership that took quick, intentional action to implement it.
As AAPL CEO and President Peter Angood, MD, FRCS(C), FACS, MCCM, moderated, each panelist frankly described their experiences with bias, and efforts to challenge and overcome them.
The goal of the 45-minute discussion?
“So we can move beyond the biases to see the value in not just diversity from a racial, religious, cultural, sexual orientation perspective but from the value in diversity of thought,” said Dian Ginsburg, AAPL’s director of career services.
Schwartz says she took a nontraditional path to becoming a physician. But she noticed early on that something was lacking in treatment of women and women of color.
“My background is actually as a labor and delivery nurse for many years,” she says. “In the taking care of patients – women – I kind of felt like there were a lot of opportunities for things to be done differently. I didn’t know quite how to point what I was feeling at that time, but it was the absence of input from women taking care of women.”
So after becoming a mother of three, she decided to go to medical school. However, more red flags came early in her career. One interaction while working at a rural Florida clinic affected her career in a profound way.
Schwartz had served her residency at Miami’s Jackson Memorial Hospital, where it was routine to test every prenatal patient for chlamydia and gonorrhea.
“I noticed that I came to this place and it wasn’t being done,” she recalls. “My first couple of charts, I happily did my routine cultures, and my partner came over and said, ‘Hey, sweetie, I’m noticing you’re ordering these cultures on all these ladies.’ And I said, ‘That’s ACOG [American College of Obstetricians and Gynecologists] standard, that what we do.’ And he goes, ‘Well, certainly, that was down there at Jackson, but our patients don’t really need to have that done.’
The next day, one of those tests came back positive. Her partner surveyed the report, “looked at the race of the patient and said, ‘Oh, what could you expect?’
“At that moment, I realized that he forgot who he was talking to, and I realized that my goal as a representative of women, of women of color, that I needed to stand up and say, ‘What did you mean by that?’ ”
But she didn’t, acquiescing “to that male-dominated culture that existed at that time.”
After 15 years, she noticed little changed “in terms of how women of different background [and] socioeconomic status were treated,” so she decided it was time for a career move.
“I decided to kind of step away from that and went to work as a hospitalist,” she recalled. “My purpose for doing that was to visit areas outside of where I had been practicing and see really what had being going on with women in the acute care setting. Of course, as I suspected, the care was still the same, the outcomes were still the same.”
Levine will be the first to admit her version of seeking authenticity is on the extreme side. “I really hope many other people don’t have to follow,” she says.
She retraced her steps, back to 13 years ago when her spouse nearly died from a “gruesome” fight against an aggressive cancer.
“Despite being a physician in a practice for 16 years, [it was] the first time that the reality of the fragility of life … hit me in the face and made me start thinking about living without a spouse and for my children without a parent,” says Levine, who was working for the Virginia health department at the time.
“In that process, something awoke in me,” she recalls. “It related to the secret that I had for probably 35 years prior.” After her spouse’s recovery, they explored options related to Levine’s gender identity.
What I realized is that this authenticity piece is something critical to the well-being of individuals that perhaps we’re not valuing it as much as we can.
Marissa Levine, MD, University of South Florida professor of population health
“I was working in a very conservative governmental environment and honestly never thought that I could do what I did do, which was fully transition and still continue to work,” she says. “But probably because of the support of family, friends and others … I’m sitting here telling you that not only was I able to transition, but I also was able to become state health commissioner.”
Levine says her personal story provided a helpful perspective on health care and diverse populations after then-Virginia Gov. Terry McAuliffe promoted her to lead the department in 2014.
“But the crux of the story that I want to share with you is this,” she says. “If I didn’t know this before I transitioned and fully moved on, the day that I came to work as Marissa Levine the first time I realized something that was so pivotal that I hope you’ve already realized and take with you and help others. I found that I had this inner strength that I didn’t know existed because I was able to be my authentic self. And I did not appreciate that for those prior 35-plus years how critical that was. And it allowed me to get though quite a bit of discrimination and some really tough things, even after I became commissioner and it got worse.”
For Perkins, inclusion within any organization begins and ends with “the No. 1 leader putting their stamp on it and saying this is important to our organization.” He says that’s the way things went at MD Anderson after Peter W.T. Pisters, MD, MHCM, CPE, was named president in December 2017.
Upon arrival, Pisters asked, “What would it take for us to be No. 1 in diversity?”
And then the new boss listened to a variety of voices before implementing a strong policy that recreated the center’s culture, Perkins says. That included hiring several women and underrepresented physicians into executive positions.
“To me, that’s a demonstration of a leader being very intentional,” Perkins says.
More than 15 languages are spoken at MD Anderson daily, and physicians “who come from every walk of life, have to deal with that every day,” Perkins says.
To respond to that global landscape, Pisters acted quickly, building a structure that makes inclusion a top priority. “We have an office of diversity; we have an office of women and minority faculty; and together we collaborate around how we recruit, retain and develop our leadership,” Perkins says. “Not just physician leaders, all our leaders.”
The structure requires strong policies that say when you hire people you must have representation that is “multirepresentative, multicultural, multigender.”
You haven’t had a perfect day unless you do something for somebody who can never repay you.
Larry Perkins, PhD, associate vice president for talent and diversity, University of Texas MD Anderson Cancer Center
If organizations are going to move the needle on inclusion — where everybody realizes they have a seat at the table — it takes modeling and intentionality by leaders, Perkins says.
“I ask you to think about, as physician leaders, how intentional are you?” Perkins says. “Intentionality becomes important with your interaction with your patient. It becomes very important with your interaction with your employees and your staff.”
Schwartz says women are significant to the correcting bias concerns “because we innately are typically nurturers and wanting to bound people together.”
It’s a philosophy in her OB-GYN practice, where she uses a centering model “specifically to do my part in this bringing people together.”
For example, “in putting my groups together, I thought if I put this woman from Nigeria with this woman from Polk County [Florida], how is that going to work out?” Schwartz says.
“What I did see is that women that are in pregnancy, carrying children, birthing together are the drivers of change. And what I saw is that those women could not hate each other anymore because they sat together, they are moving through pregnancy together, they are raising their children together and it is powerful to see how that would contribute to change.”
Levine values such generative relationships, “where both parties are better off” because of their connection or bond.
Acknowledging and accepting authenticity applies to the individual as much as the organization. It involves recognizing a person’s differences and related tribulations.
“And from a public health perspective,” notes Levine, “I really wonder if this isn’t a root issue with some of the issues we are dealing with today, [including] substance abuse and trauma-related issues, that we have generations of people who have in many ways possibly because of our social context, our beliefs, our policies, have been limited to pursue authenticating themselves.”
Levine stresses the importance of daily actions in terms of diversity and inclusion. Research has shown that an organization that doesn’t support authenticity creates stress and lacks diversity.
“How many of us are actually living authenticating lives,” she says. “I suspect being around a room full of very confident people … you still have a tremendous opportunity to impact the pursuit in a positive way of other people who are seeking that.”
From a population perspective, Levine is concerned about implicit bias filtering its way from the individual to institutional level, where it affects policies, cultures and patient outcomes.
“At the community level, it results in lack of care, lack of competency in dealing with certain populations,” she says.
These gaps in coverage are problematic and avoidable. For starters, she suggests organizations make use of community health assessments to understand what health care issues a population is dealing with and how they can be addressed.
“I feel very accomplished, I feel very fortunate, and I’m privileged in many ways, but I have to tell you the gaps that were obvious in the care for people who had issues that I was dealing with were tremendous. I was able to find caring people, but they had no competency. And that’s almost as dangerous, maybe even more dangerous,” Levine says.
Always remember to use leadership in your daily clinical activity. That patient that you are interacting with, that person would appreciate an understanding of where they’re coming from, at least that you respect and would like to know a little bit more about it, and goes a long way.
Pamela Schwartz, DO, OB-GYN
“And it was only because I’m a physician, and I could learn too, I knew a lot about the issues I had to deal with, [that] I literally had to guide providers. But I couldn’t find certain individuals in the community who could help.”
Each panelist says that recognizing and reconciling hidden bias begins with dialogue and learning how to engage with peers and diverse patient populations.
“I think that there’s still a lot of work to be done in the basic conversation about race and race relations, how we relate to each other, and as physicians how we can start the conversation that hasn’t been had to better care for our patients,” Schwartz said.
Adds Perkins: “I think it’s through these forums of self-exposure that you grow as a leader. [At MD Anderson] we have created forums like this on a regular basis in our organization to have these spoken discussions, and kind of force discussion. As a way of institutionalizing the implicit bias part, we now require implicit bias training in our leadership training. We require that anybody who is on a selection committee to hire another person takes subconscious bias training.
“So that we start to pull back our own onion.”
Levine says she’s a big believer in physician leadership, and that all physicians have a role in developing and recognizing authenticity.
“I’ve got to wonder if you as authentic leaders can value those interactions in the most positive way and appreciate that every day you might be able to positively impact that person in front of you and allow them to continue their journey to authenticity,” she says, “that you might do the public health good and be part of the collective action that I think we need so critically where we’re all aligned, supporting one other, perhaps first realizing our own … authenticity and supporting others.
“Perhaps if we look at diversity and inclusion in that way, you might be more empowered and more thoughtful about everything we do. Each of you will be better off because of this, so if you don’t do it for any other reason, do it for that reason.”
Rick Mayer is a senior editor with the American Association for Physician Leadership.