Changes to the Step 1 Scoring System: Transparency and Underrepresented Minorities
In part 4 of this video series, Dr Adam Friedman, Dr Ilana Rosman, and Dr Kamaria Nelson discuss the need for residency program transparency.
In part 5 of this video series, Dr Adam Friedman, Dr Ilana Rosman, and Dr Kamaria Nelson discuss the importance of cultural sensitivity and addressing racial bias in residency programs.
Dr Rosman is the Residency Program Director, director of the Dermatopathology Center, and associate professor of dermatology and pathology at Washington School of Medicine in St. Louis, MO.
Dr Nelson is a research fellow and incoming resident with the Department of Dermatology at George Washington University School of Medicine in Washington, DC.
Dr Friedman is the Residency Program Director, professor and interim chair of the Department of Dermatology, and director of Translational Research at George Washington School of Medicine in Washington, DC.
Dr Ilana Rosman: Kamaria, what would you like programs to do [laughs] in that setting?
Dr Kamaria Nelson: I kind of like what you guys discussed. Because microaggression, it’s very real for an underrepresented minority, whether it’s in the medical field or just in life, microaggressions are always there.
It’s something that skin of color and minorities go through on a daily basis. I would want programs to understand that something like current events may be affecting how they’re performing at work. [laughs] I’m trying to figure out...
[crosstalk]
Dr Nelson: I think just having programs just aware of these microaggressions and how it may affect their residents and applicants are important. [laughs] It’s important to me, and I think it should be important to programs.
Dr Rosman: Really, again, the work is on us in positions to make it happen, in positions of power, and also on us as white people. We can’t ask our students of color to be doing all of the work for us here. We have to be starting those conversations with our white faculty members and obviously being inclusionary.
Whoever wants to be involved in that process, we want them to be involved in the process but making sure that we’re leading the way and not putting the burden on people of color who already are dealing with the burdens of this.
I think everything that Adam brought up is really excellent. I think where a lot of programs are doing this, we’re trying as well to think about how do we incorporate curriculum that focuses on healthcare disparities and on skin of color and just what we can do in dermatology but also incorporating that into just our regular curriculum as well so that it’s integrated.
There are separate lectures that focus on these things. For example, every dermatology residency program has a didactic curriculum that includes kodachromes and lectures and all of that.
So we are telling our faculty and our residents, “When you make a lecture, keep in mind what needs to be in that lecture. If you’re going to show a picture of psoriasis, show a pictures of psoriasis in a black person.” It doesn’t have to be always the textbook pictures of psoriasis in white people.
[crosstalk]
Dr Adam Friedman: This goes for students also, med student lectures. Yeah, absolutely.
Dr Rosman: Yeah. It seems like oh, that’s relatively simple, but I think it can be pretty powerful just to have more diverse representation in our teaching. There’s already been studies about this too, looking at textbooks, that it’s just woefully underrepresented. Skin of color is woefully underrepresented in dermatology textbooks and literature.
So I think whatever we can do to increase diverse representation in every lecture because all of these skin conditions affect everybody. [laughs] They don’t affect only white people. They don’t affect only black people. We need to have that diverse representation in every aspect of education that we do.
Dr Friedman: I think also in terms of there’s low-hanging fruit, and then there’s the long-term goals. I think we have to push away silence. I think that’s one of the big things, is that we sit by, and when we get uncomfortable about certain topics or even certain words, we’re silent.
I think one of the big ones is racist or racism. We’re so scared to say that and call things racist. I think we have to get comfortable doing that. It doesn’t necessarily have to be a negative thing. It’s just simply pointing out that something that you say, a microaggression, is racist. If it has such a negative connotation, then that person gets defensive. They miss the lesson.
I think we have to be ready to say, “What you just said is racist. That’s OK, but it’s not OK if you don’t learn from that.” Shame on me for not saying something to you when you said something that you didn’t even realize was hurtful. Granted, intent is irrelevant. It’s the impact that’s most important, but if you don’t say anything, guess what? It’s going to keep happening.
I think as program directors in positions of leadership, our faculty, our colleagues are going to follow our behaviors, and our residents especially and, going down the line, even students.
So I think it’s really important from the get-go. We can’t be silent. We have to be ready to say things to people that are going to make them squirm and to feel awkward. We do it in the most cordial way possible, but we need to be vocal. I think we’re so used to kind of avoiding.
It’s even like the waterfall in the background. You don’t even hear it anymore. People have gotten so used to just avoiding it that it’s become happenstance and normal behavior. It can’t be anymore. We have to be vocal. We have to start, to your point, including a diverse array of phenotypes in all of our lectures.
We’ve gotten feedback in past years from the med students being like, “Why was there not a single patient of color, not just black, but patient of color, period, which is a rainbow of different patient types in this whole lecture.
That’s unacceptable. I think usually, there’s like, “Oh, well, I’m so sorry.” We got to be like, “You’re right. You’re right. I screwed up. I’m sorry. This is going to change.” I think that’s the only way things are going to change.
Dr Rosman: Yeah, and I think, as you said, make sure that we are able to...You don’t want to get stuck in the callout culture without the support after it, right?
Dr Friedman: Exactly.
Dr Rosman: Because people need the tools. I mean, I have to say in the past couple of weeks, I consider myself someone who’s been very progressive and interested in these issues and wanting to work on diversity, but I know I haven’t been doing nearly as much as I should be doing.
Last weekend, I sat down to reach out to one of our residents who is a person of color, to reach out to an incoming resident, and to reach out to the residents in general. It was really hard for me initially because I was sitting at my computer. What do I say? I want to say something, but what do I say?
Honestly, I was just honest. I said, “This is terrible, and I’m here for you. I think we just need to start, and I will tell you once I did that, it was easier to then continue the conversation and to talk about it on social media and talk about it in person and on email. Well, over Zoom, since we can’t do anything in person anymore.
Dr Friedman: [laughs]
Dr Rosman: We’re having a session this week with the residents. I think we need to exercise that, right? I think it’s easy to get out of practice or maybe never been in the practice of doing it. It is hard, and it is uncomfortable. We have to just push through that discomfort.
As you said, Adam, be a role model, or not even role model, just model behavior for our mentees, our students, and our faculty. Then also give them the support. If they see us doing it, then it’s easier for them be like, “Oh, OK, I can say something because they’re also saying something.”
I think we can then give people the tools because I think a lot of people want to do what’s right, but they don’t even know how.
Dr Friedman: Right, right. I don’t think any of us truly do. I think that’s why we got to work together. We need to be all inclusive group who figures out how to do this right. This is all uncharted territory.
Dr Rosman: Yeah.
Dr Nelson: I think residents and medical students are already a vulnerable, I guess, like population. They don’t want to make any mistakes. They don’t want to cause any unnecessary tension or drama or anything like that.
I think if programs are transparent and saying if you do go through this racial experience or any kind of conflict about race or anything like that, I think students and residents should be comfortable about bringing it up. There shouldn’t be any repercussion for having experienced that situation.
Dr Rosman: Yeah, I’ve seen a lot of students and residents talking about this on social media and even junior faculty saying, “I don’t feel comfortable posting my views or even saying something about what’s going on because I worry that the my program director, my colleagues, my chair, or other faculty will view that negatively, and I will kind of suffer for that.”
If they see people who are have that power, saying something, then it kind of gives them a little bit more freedom to feel comfortable doing that. I think that’s our job.
We have to make sure that our trainees, junior faculty, and students of color feel comfortable talking about this, feel comfortable coming to us, and feel comfortable bringing up suggestions of how to make things better and not that it’s on them to do that.
But if they want to be involved in that process and want to reach out to us, we have to make sure that they can do that and that they feel comfortable doing and I think that’s why we have to push away the silence as you said, Adam.
Dr Friedman: Yeah, I was on a Zoom call last week for Diversity Network at GW. I think it was an internal medicine resident who made the comment of the 'suffering smile' that you go through your day you hear these things, and you just smile through it because you’re afraid of saying something. You’re afraid of rocking the boat. We’re not going to change that culture unless we, once again in these roles, are the first to break that silence.
The second part of that comment that this resident made was that when she came to morning report that week, that Monday, right after George Floyd was murdered and obviously a lot of civil unrest, her anticipation was it wasn’t even going to be mentioned. It just gonna be skirted over.
That was the first thing the program director mentioned, which I give her a lot of credit for, just right out be like, “This is what happened. This is horrible.” I think that’s something we could do in parallel to that. Just like you said, you send out an email, which is not easy to do.
If we bring it up first, breaking away at that little bit of armor, that suffering smile, that it’s not going to be a suffering smile but rather a suffering will be made, vocal in a very open and accepting manners. I think, once again, we’ve said it a million times. It’s on us to model that and show it’s OK to not suffer in silence.
