Why Diversity, Equity and Inclusion is Imperative in GME Training

Podcast Transcript

Dr. Jamie K. Stoller:

Hello, and welcome to MedEd Thread, the Cleveland Clinic Education Institute Podcast, that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Jeremy Lipman:

Hi, and welcome to today's episode of MedEd Thread. I am your host, Jeremy Lipman. I'm a colorectal surgeon and the DIO and director of graduate medical education here at Cleveland Clinic. And today, I am very fortunate to be joined by Dr. Ruth Bell, who is a resident in our internal medicine program. Dr. Bell did medical school in Texas and completed her internal medicine residency here at Cleveland Clinic, and is currently serving as a chief resident, and is also the president of our health staff association. And currently, she is interviewing for GI fellowship. And if there are any GI fellowship directors out there listening, I, I can't encourage you strongly enough to take her into your program. You'll be very fortunate to have her. So, Dr. Bell, thank you for being here. Welcome.

Dr. Ruth Bell:

Thank you for the warm welcome, Dr. Lipman.

Dr. Jeremy Lipman:

Yeah. And today we're gonna be talking a bit about diversity, equity and inclusion in training programs. And this has been a really popular topic lately, something really important, but maybe we should start by framing it. So, Ruth, why is it important, and what are the benefits of having a diverse training program?

Dr. Ruth Bell:

Yeah, absolutely. That's a great question. So, the benefits of having a diverse training program stem from all aspects, especially when you're thinking of patient care. And here we have our motto of having patients first. And if that is what we stand by, then our training and our faculty should reflect the audience and our patient audience from that standpoint. It's very important in medicine that there is constant innovation, and you find when you have kind of a one way of approaching things standpoint, that innovation is hindered, in a way, shape, and form. So having that diverse training background allows for a diversity of thought, also allows for a diversity of culture, race, ethnicity, gender, essentially diversity in as many ways as you can think. And I think that that is helpful, not only to our patient population, but to medicine as a whole from that standpoint.

Dr. Jeremy Lipman:

Are patients more likely to get better care if they're seen by people and providers who better reflect their values and their background?

Dr. Ruth Bell:

Oh, absolutely. At the height of the pandemic, I was a part of a lot of COVID vaccine processes, and the question continuously was, how do we get the vaccine out to the minority communities? How do we get our colleagues with fewer resources, get this out to them? And it was interesting to me, because at that point in time, I realized that the concern and the conversation was actually not the core issue. It was not getting the vaccine to the minority population, although of course, that's a huge thing. It was really, even if you get it to them, they won't take it. Because there's so much distrust in the medical community, especially in the African American population, that even if you get it to them, they will be hesitant, and they would be concerned as either being an experiment or guinea pig, just given the history that we have with the medical field.

And I will say that it has an internal medicine resident, I would often hear my attendings talk to our patients about getting the COVID vaccine and they would say, no, I will not. And then they look at me and they said, did you get the vaccine? And I would say yes, and all of a sudden, then, the conversation would change, you know, we were able to have a very honest and frank conversation about their fears. And I will say that just having that sense of community, and that shared background, honestly, I was watching it happen live truly made a difference.

Dr. Jeremy Lipman:

That's really an incredible experience, and I think highlights so much of the value we're talking about here, but certainly there's a, a lot of value in having a blend of thoughts and ideas. But when the rubber hits the road, it's about taking care of the patients and if we're going to provide better patient care with a diverse community of trainees and faculty and, and that really has to be driving us forward.

Dr. Ruth Bell:

Absolutely.

Dr. Jeremy Lipman:

So, I think when we talk about diversity, equity and inclusion in training programs, it really comes down to three elements. There's the recruitment to build up a training program that is diverse. There's the retention of trainees from underrepresented backgrounds, which leads to inclusivity, and equity, and then promotion and helping people to make that next step that jumps into their faculty positions and beyond. So, let's start by talking about recruitment. And maybe you could talk a little bit about some ideas or strategies that are important from the program perspective in recruiting a diverse trainee population?

Dr. Ruth Bell:

That's a great question. I will say that, as we're approaching our interview season, at least from an internal medicine program standpoint, one of the things we've been very intentional about is reaching out to SNMA, LMSA, our minority organizations, hosting open houses and reaching out to historically Black colleges and medical schools in terms of a, hey, Cleveland Clinic is a wonderful place to train, and we are looking for residents just like you. It's easy to say one thing, but until you actually go out there and put it in action and get in front of the audience that you say you want; you're not really practicing exactly what you preach.

So, I will say that despite your current state as a residency, as a fellowship, effort is appreciated. It's easy to say one thing and check that box on the website that, yes, we believe in DEI. But unless you're going out there, and really making that known that, hey, not only do we believe in DEI, but here we are actively trying to recruit, because we think that you would add to our culture, that's really one of the, the main ways that programs would be able to do you the recruitment aspect of it.

Dr. Jeremy Lipman:

So, you mentioned the, the SNMA, which is the Student National Medical Association, which is a student-run organization focused on Black medical students in the United States, and the LMSA, which is the Latino Medical Student Association, also student-run program. Do you recommend that students who come from underrepresented backgrounds get involved with these types of organizations? Are these useful as it is helping them to make the transition into residency and beyond?

Dr. Ruth Bell:

Oh, absolutely. A lot of medicine, minority or not, but a lot of medicine has to do with networking, and the LMSA and the SNMA are great resources in terms of getting access to various residency programs, program directors from that standpoint. So, I would always encourage, for example, people who are interested in GI, they go, and they join a GI society, similarly with all of the other subspecialties as well. And I would encourage if diversity, equity and inclusion is something that you are really looking for in a program, take advantage of the programs that are championing this already, and whose mission or core mission it is. That way, you don't have to reinvent the wheel.

Dr. Jeremy Lipman:

Yeah. Great points. And when programs are looking to engage in this work, sometimes they're starting at a disadvantage. They're a very homogenous program, they don't have many underrepresented groups represented in their teaching faculty or in their residency program. So, what should they do? How can a program change its culture, change its makeup, modernize, and take advantage of these benefits of diversity?

Dr. Ruth Bell:

That's a great question, you know, because I, I will say you do have to start from somewhere. What really matters is just the effort that's put out there. So, talking from perhaps a slightly different perspective, I'll talk about how applying to residency was like for me as a DO. So, for example, despite the fact that I was a competitive applicant, there were certain places that I actually did not apply to because the rumor and the culture of that place was that it was not a DO friendly program, and I didn't want to waste my time, or my money, or their time either.

And then there were other places that I also interviewed at that weren't necessarily known to be not DO friendly. But if you look through their alumni and look at their current class, they never accepted a DO, which usually was a warning sign to me. But when I was there, and when I was interviewing, they were very intentional in the things that they said and the things they talked about with me whether it was regarding DEI initiatives that, you know, perhaps they wouldn't have mentioned otherwise, or in regards to faculty that maybe I wasn't aware of that word DOs, and the fact that they recognize this is an area that I'm lacking let me make sure that that areas addressed regardless of me volunteering that or even saying that it automatically moved them further up on my rank list.

And the places that actually went out and recruited from osteopathic medical schools, they were changing the tone and the rumor that they had about that institution of not being DO friendly or not previously taking DOs, because again, here, they are actively saying, we value you, and we want you to come here. So in the same vein, similarly, with underrepresented minorities making that effort, going to the various spheres, going to their schools, all of those things, or even, you know, on the actual interview day, I really appreciate it when we would have a meet and greet, I had the opportunity to talk to minority faculty or minority house staff, if that's an option. All of those things ring in the minds of your applicants' heads when it's time for ranking.

So even if yes, that hasn't been the historical way that the residency program has looked, it's not hard to imagine where this program could be in the future if these efforts are continued. So, I would just get out there, really put the word out, be intentional. It is okay, to me, at least, to tailor interviews to make sure that that exposure and that chance to have that conversation is bad, because when I interviewed here at the clinic, I won't lie, I remember exactly the second-year resident who talked with me, who was a minority as well. And I was like, wow, okay. Are you happy? And sure enough, it was, uh, a genuine conversation. So that's kind of what I would encourage.

Dr. Jeremy Lipman:

That's great. So, change is possible. It certainly has a lot of benefits. Let's talk more, though, about the resident's perspective. So, you, not that long ago, went through the process of finding your internal medicine training program, you're, again, going through the application process to become, uh, a fellow. So, what are some things that students who are underrepresented should be looking for to try to identify the right program for them? It's very easy for programs to create a nice web space or to create some promotional materials, but how can they really know that the program they're going to will be welcoming of them, and that they're gonna feel included and feel like they found their home?

Dr. Ruth Bell:

I love that, because as you said, I'm currently going through the process myself with applying for fellowship. And it is something that is very important to me, because, you know, where you train matters, and you definitely want to feel as though you're a part of the community and not an outsider. So, something that I've kind of picked up on throughout my time interviewing both as a resident and now as I'm applying for fellowship is, it is okay to ask the same questions to the trainees that you asked to the faculty. And I don't do it in terms of that, oh, I need to have X number of questions to ask, every time that way, when they say, what questions do you have? I have a list. I do it on purpose, that way, I know if there is any mismatch between what I'm hearing from the trainees, and what I'm hearing from the faculty.

So, one of the questions I choose is describe the culture, and I pay very close attention to the words and the emotion that I receive from the trainees, and I pay attention to what is also considered important as part of the culture is from the program leadership and from the faculty. And if those same words consistently come up that, we are inclusive, collaborative, welcoming, things like that, I'm like, okay, from top to bottom, you know, everyone has the same idea of their culture. But if I'm hearing, you know, maybe the faculty prioritizes innovation or something, which is not a bad thing, and they think that their culture is more focused on the medicine aspect of things, and I don't hear that there's a sense of teamwork and being collaborative and being collegial or being inclusive, but then I hear maybe vice versa from trainees, I say, okay, one of these things is not like the other.

So that's one of the questions I asked. The other is, what are your DEI initiatives? And again, there are key phrases that I'm looking for. If I'm told of all of the initiatives that I'm talked about, if they're being led by trainees, if it's a fellow-run initiative, or resident-run initiative, or medical student-run initiative, I'm honestly impressed and I love it, and I think it's commendable. But I get concerned, because I wonder if that trainee is not interested in fulfilling that role, will that initiative still continue? Is it sustainable?

Versus when I asked this question, and I'm told us initiatives that are grant funded or have opportunities or are back from GME leadership, I know that this place is a place that puts their money where their mouth is. They've value DEI enough to not just have resources finances behind it, but they have the infrastructure behind it as well. Now, it's a top-down approach, and it's not dependent on the trainee. It's sustainable, and it tells me that it is a part of the culture. My two main things that I'm looking for. Is this something that from the leadership on down is valued, and what is the culture of the place? So those are typically the questions I advise people to ask.

Dr. Jeremy Lipman:

I think that's really valuable advice. And, you know, it gets to another question I had, which is about trainees that come from underrepresented backgrounds who often find themselves being put in a position to help with these initiatives a lot. And, you know, that's not everybody's wheelhouse, it's not what they're interested in. So, what do you advise the trainee who comes from an underrepresented background, but doesn't want to get involved with this stuff, doesn't want to be part of recruitment and retention efforts, they, they just want to do their program and, and move on to the next thing or do their research and move along, this isn't their area of interest? But how can they do that, and yet still be seen as part of the team and, and a professional member of, of the training program?

Dr. Ruth Bell:

I think that that is actually something that's very difficult for a lot of minority trainees, because you have that desire to help, but are not always able to. And I, I just want to emphasize and say that that is okay. There is no obligation or no, no need to feel obligated to be the token anything or to be the representation or the voice or any of those things, because what is important to keep in mind is it there are only 24 hours in a day, and if you say yes to one thing, you say no to something else. So, meaning, if you decide that your passion is DEI that is phenomenal, and if you're able to marry DEI with research, or with community service, or with leadership, that's even better, because now you're able to move forward your career and move forward your passion as well.

But if you find that in saying yes to one thing, you are not able to accomplish the expectations or the research or whatever goes along with being a trainee, it's okay to prioritize your medical education, because I do find that sometimes there's this minority task, where you feel as though, I have to carry this banner, I have to do this." And if you're at an institution that doesn't value DEI, even though you're on all of these committees, and you're al- doing all of these leadership programs, the people who are getting recognized are your peers who are publishing papers and who are being, I guess, productive, and it can be at a disadvantage.

So again, that's why I said, it's very important to make sure that the institution that you're at and you're training yet, is putting their money where their mouth is. It's a top-down approach. It's not dependent on you. If you decide that you're not interested, that is okay, the initiative will continue to move forward. So, I think it's just important to always keep in mind that, you know, you do not have to commit to anything that you don't find that you have the time for.

And the other thing that I just want to make sure we all are on the same page is, if you are interested in DEI, that is phenomenal. But always follow the resources, there are certain things that people will say, hey, Ruth, I think you would be perfect for this. And I will say, tell me more. And when I realized that this is something that will not enact the change, that I think it could, I said, thank you for this opportunity. I don't have the bandwidth for this right now. But I can reach out to someone else who may be interested. And that way, you know, those initiatives are still moving forward, even if it's not my responsibility.

Versus when I hear initiatives and they tell me, yes, we just received a grant funding for this. Ruth, I think you would be a wonderful voice here. I'm like, you know what? There's manpower, their support, I feel as though if I were a part of this committee, we could really affect change. Now, I'm willing to commit to that, versus committees that are just there to say that they have a minority or whatever the purpose is on staff. So, you can pick and choose, or you can decide not to be involved at all and that is, okay. At the end of the day, we are here to put patients first and also to put our training versus law.

Dr. Jeremy Lipman:

Well said, you know, understanding your own drives and interests and the opportunity that you have, the bandwidth that you have available to, to put into these things. So, you know, you mentioned committee involvement and whatnot. You are the president of the house staff association here. We have a lot of house staff, and you provide them with tremendous resources. Can you talk about some of the things that you're doing that focus on that inclusivity piece, the retention efforts to make sure that those who come from underrepresented backgrounds feel like they're welcome here, that makes Cleveland Clinic, their training home, perhaps provide some examples and some recommendations for other programs that want to build on their own efforts?

Dr. Ruth Bell:

People will stay in places where they feel welcome. And so, the house staff association, when I initially started on the committee, I started off as the DEI co-chair, graduated to vice president and now I'm president, but my passion is still DEI initiatives. And I will say that a few of the things that we started and are still currently doing, there's quite a few, but I'll start off with our food for cultural education. So, the clinic is a very diverse place. We have trainees from all over the world, from various backgrounds in terms of race, ethnicity, gender, social economic status, and in all forms and ways. The clinic is a very diverse training program for both the fellows and the residents.

And we wanted to really highlight that, and let people know that hey, there is so much here that we have to offer. So, with the food for cultural education, about once every month to once every other month, we host a fellow, a resident from a different culture, anyone who's interested in speaking on their culture, and we cater food from a restaurant of their cultural background as well. And over the new hour, they give us a lecture about their culture. And they have the full ability to do and talk about anything that they're interested in. So, if they want to teach us a few words, if they want to talk to us about the food that we're eating, for the day about the history of their culture, and their people, the language that's spoken there, anything that they really interested in may have the opportunity to share it.

A few of the cultures that we've hosted, for example, Lebanon, we've hosted Israel, in addition to these areas, sometimes it's just to help raise awareness. And what we'll do is either have fundraisers, if there's something going on in that country that we didn't know of and find ways to support even if it's not with cash, we have helped donated medical supplies, for example, to a few of the cultures that we have hosted. So that's one of the initiatives that we have here. Another initiative that we have is our medical Spanish courses. So, we partner with the medical students in the medical schools, to help teach our trainees how to speak medical Spanish, both from a beginner perspective, and from an advanced perspective, we offer those classes to them. And then I'll just talk about two more, there's quite a lot. The last two are two that are newer and that I'm very passionate about.

The first one is our MUST lecture series. Essentially, it stands for Mentorships of Underrepresented Students and Trainees. And it's just a safe space for any of our trainees who are underrepresented minorities, to come and to talk about life and medicine and life outside of medicine, and how to find mentors and to navigate the culture. We've had speakers come and talk to us such as Dr. Quinn Capers. We just kind of have an open virtual forum where trainees are allowed to speak without fear of repercussion. There are no faculty present. So, we just can have that sense of community. And from that we've actually started a mentorship program, which peers the underrepresented trainees with faculty and staff and even medical students as well who also identify as underrepresented in medicine.

And then the other initiative that we have is in partnership with Case Western Medical School as well as CCLCM, our Cleveland Clinic Medical School, we've received grant funding, all of these things are backed by GME, have funding through HSA. So this one, we just received grant funding for our horizons pipeline, where we have underrepresented high school students, undergraduates coming to the medical school, to participate in various interactive workshops that are led by the medical students, as well as the trainees, the residents and the fellows, to introduce them into medicine, because honestly addressing these disparities, and the lack of diversity in medicine starts at a young age. So, our hope is to start with the high school students and with the undergrad, eventually, over time, we're hoping to expand, we call them families, expand the family further back to the middle school and into the elementary school age, and really get them exposed to medicine even earlier. Those are the kind of things that I'll speak about today.

Dr. Jeremy Lipman:

Yeah, those really sound like fantastic initiatives. I mean, what better way to feel at home and to have your community of co-trainees supporting your home community with donations of time and resources to people they don't even know. But just because your part of that community, they want to help you out. And I also heard you saying that many of these programs are open to whoever identifies as being underrepresented because many of the underrepresented groups in our training programs would have to acknowledge that themselves, they're not things that you can see or written down anywhere. But they may come from backgrounds that aren't frequently found in medicine and may feel isolated. But it sounds like most of these programs are open to anyone so that they can help to build their community while they're here.

Dr. Ruth Bell:

Absolutely.

Dr. Jeremy Lipman:

Well, Ruth, congratulations on all the incredible work you're doing. And thank you so much for the many contributions you've made to enhancing the training and our programs here and wishing you best of luck on your next phase. And so, to Dr. Bell, thank you so much.

Dr. Ruth Bell:

Happy to be here.

Dr. Jeremy Lipman:

It's been a fantastic podcast. And for our listeners, thank you for being here and I look forward to having you here next time. Have a perfect day.

Dr. Jamie K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute Podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.