Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications
[00:00:15] Speaker B: in the world of orthopedics and beyond.
Good morning, Mark. I'm hoping it's a little warmer where you are than where I am, but we've had some cold spells recently in Southern Ontario.
[00:00:28] Speaker A: Well, it's, it's been brutally cold here, and it's going to get worse this weekend. So what, what's your number? What's your temperature now? Let me look here.
[00:00:35] Speaker B: Well, actually, today it's going to be a high because we have snow coming in, so it's going to be negative one. Celsius will be the high, but we've been down in the negative 16, 17, 18 Celsius.
[00:00:48] Speaker A: Yeah, I think we got to beat by a few degrees. It's, it's a, it's, it's a little bit warmer today, 10 Fahrenheit. So.
[00:00:57] Speaker B: Yeah, okay.
[00:00:59] Speaker A: But, so as you can tell, I'm outside the operating room shortly to do a case which I had to add on, related to pickleball trauma, which I, I really do think we need to do. We need to do an Ortho Joe on pickleball. But so unfortunately, I don't, I don't have my, I don't have a Tim Hortons. I don't have the Boston favorite Way to Go. I have minuscule mug from the, the lounge of. Or bad coffee. So. But it's still coffee and it's, it's helping to get me ready for the case, so I'm set to go.
[00:01:36] Speaker B: Well, listen, you know, Mark, you and I are just lifelong learners, and today we have an amazing expert on with us, a friend to the Ortho Joe Show, Dr. Saroo Sharda, who is an anesthesiologist, but also the Associate Chair of Equity and inclusion at McMaster University.
And, and, you know, I think you and I are about to learn some stuff today, which is great, and I'm hoping it'll be also learning for those of, those of you who are listening in or watching this podcast. So welcome Saru, and thank you so much for taking time with us this morning.
[00:02:07] Speaker C: Thank you. Always lovely to be with my orthopedic colleagues.
[00:02:12] Speaker B: Isn't that nice? Anesthesiology and orthopedics coming together. I love it. I love it.
[00:02:16] Speaker C: We have a very unique relationship, as you both know.
[00:02:20] Speaker A: Are definitely a team on a daily basis.
Dr. Sharda, you, you were kind enough to come on this podcast, I don't know, a year and a half or so ago about DEI topics and what. What we would really like to have you focus on today is the whole topic of microaggressions.
People like me, you know, people of Caucasian background.
My grandfather immigrated from Poland in 1910. You know, I've been, you know, enfolded into America. I'm an American, Caucasian, American. I have little experience from this except for, you know, in my teens when the Polish jokes used to be out there. I don't think anybody's old enough on this podcast, but there used to be a time when Polish jokes were. Were rampant, but. And they were kind of funny, not really assaulting, but insulting. But I think those of us in the orthopedic community, particularly around the issue not only of racial and ethnic heritage, but also we've struggled in our field with women in orthopedic surgery.
I think a lot of times there can be these microaggressions around women who may not be as big, as strong as the mythical orthopedic doctor who's 6 foot 2, 200 pounds, a former sports athlete.
Maybe we could just have you start out. Is there a definition of microaggression?
[00:03:46] Speaker C: Yeah, I mean, there's a number of definitions out there, Mark. Sort of a high level, simple one is microaggressions are subtle insults, whether they be verbal or nonverbal, that perpetuate and underscore stereotypes or derogatory beliefs about people who belong to marginalized or oppressed groups.
[00:04:11] Speaker A: Yeah.
[00:04:11] Speaker C: So what's really important, though, I think, to understand, and something I wanted to underscore in our conversation, so I'll bring it forward right now, and I'm sure we'll get into it more, is that while microaggressions tend to manifest interpersonally and actually what you say about surgery, and in fact also anesthesia, is born out in the literature. When you look at the literature, most of the microaggressions that are happening in medicine, and I'm being a little physician centric here, but they. They are the highest in surgeons and anesthesiologists, specifically women, and specifically those belonging to racial minorities.
But what I wanted to point out is that although these things tend to manifest interpersonally, what they are are symptoms of the systemic, bigger structures of discrimination and oppression that exist not just in medicine, but in society. And of course, in medicine and healthcare. We are a microcosm of that society. And so it's really important for us to understand that, yes, we need to think about how do I respond to a microaggression, what does mean for me in the moment as a clinician, as a leader, as a team member, as a colleague, as a friend.
But actually what are the upstream structural things that we need to think about and how do we start intervening structurally and systemically, much like, you know, when folks might come to you because there's a gangrenous limb that needs to be removed. Yes, we're going to do that. And we're also going to think about what was the glycemic control in this patient who's living with diabetes and you know, was that contributing factor?
[00:05:45] Speaker A: Well, thanks for that. I'm going to move, if you don't mind, I'll ask another question and then give you your turn.
You mentioned in your response about verbal and nonverbal, and I think this is a really important area, particularly for us males, particularly Caucasian males in orthopedic surgery, to understand.
Can you just say a little bit more about the non verbal stuff? Are these non verbal things really being done with any sort of premeditated intent or maybe where it comes from? And what, what sorts of things are we talking about?
[00:06:25] Speaker C: So let's talk about some examples, Mark, and then we'll talk about intent versus impact, which is a hugely important concept. So I'm glad you mentioned that word intent. And then we'll talk about sort of where does it come from.
So some examples could be, let's say we have a resident or a colleague who is living with a disability and perhaps, you know, they can't take the five flights of stairs that we're all running up, you know, to go see the next patient on morning rounds and they express that, you know, they're going to, they're going to go in the elevator, maybe there's some eye rolls, maybe there's some kind of looks between everybody like they're not going to take the stairs. Similarly, perhaps they need other certain types of accommodations.
Again, we might see some non verbal behaviors around that. In terms of intent, there is usually, I would say in my experience, not just from the literature, but in my experience of having done equity work now, including as the associate dean right now for over 10 years, I would say very infrequently, is there mal intent? Right. I think we're all pretty altruistic people in medicine. We see ourselves as people who are here as a helping professional, as a, as a healing professional.
But what we don't always understand is that impact can be very real without mal intent. And so this is really important concept of intent versus impact. And in fact, most of the time when we're having conversations with people about microaggressions about these topics, one of the emotional defenses, that is a very human one is, but I'm a really good person and I have friends who are women and friends who are black and friends who are trans.
And of course that's not what it's about.
And that's when it comes back to again, what we talked about earlier. Society is set up in such a way that certain groups are given more inherent worth than others. And that's not about anybody being good or bad or this, you know, I usually put up this Batman vs. Joker slide in my talks, right. It's not a dichotomy like that. It's a nuanced, complex thing about how society has been set up and therefore we see these things manifesting. Another common one I'll, I'll give an example of, and this is not a non verbal one, it's, it's a verbal one is when somebody has a name that perhaps is more challenging to pronounce. This idea that, oh, I could never pronounce your name, so let's just call you Joe.
Like the invalidation of somebody's identity and particularly when you add in a power dynamic to that right, Like a, a learner.
But the invalidation of that right, of somebody's identity and what it, what, what is carried in a name and the fact that we can pronounce all kinds of really complex medical terminology and yet we're saying we can't pronounce somebody's name. So those are just a couple of examples. And of course we can get into more. We wrote a paper about this a couple of years ago and we have a whole bunch of examples in there as well. If people want to kind of do a deeper dive after listening to us.
[00:09:23] Speaker A: Hugely sorry, we'll definitely attach that, that reference for those who like to dive deeper. But I just want to reemphasize a short sentence. You said that impact can be very real without mal intent.
[00:09:38] Speaker C: Absolutely. And impact can lead to harm. And I don't use harm lightly. I think harm and safety are two words that sometimes get bandied around a lot without really understanding what it means. There's a difference between being uncomfortable and actually experiencing harm. And I think those two things often get very conflated. But there are experiences that actually lead to harm. And in fact the microaggressions literature now tells us that when you are at the receiving End of microaggressions in a chronic way, you're actually more likely to have cardiac disease like hypertension, other cardiac manifestations as well. You're much more likely to have burnout at work. And again, in the medical literature specifically, that is higher for women, particularly women in surgery and anesthesia, you are more likely to have mental health issues. So this is not just like, oh, somebody made me feel bad. There's actually very real manifestations of this. And there's now actually some really interesting studies around brain imaging showing what happens in our brains when we are exposed to this kind of chronic discrimination.
[00:10:43] Speaker B: You know, Sarah, you must have a sense, like, if you were. And again, it's always hard to put averages and numbers to this. But, like, how common do you think on a daily basis in most, I'll say orthopedic or surgical ORs, where these things are happening?
Sometimes what typically happens is all that, that's horrible, but that doesn't happen around me.
But I have a feeling that part of this always is if you are aware that it's happening, you're a bit more attentive to it. And then I guess the question, what do we do? But maybe the first question from your experience is, how often do you think it's happening in a typical day? Typical.
[00:11:15] Speaker C: Or we actually have data on this mo again, which is included in our paper, because there actually have been surveys of this. And of course, we know survey data isn't perfect, but have a ballpark kind of figure, which I would say anecdotally would match my own experiences. And of course, you know, I come into the operating room with a lot of privilege. And I also come into the operating room as a fairly petite South Asian, you know, relatively softly spoken, but, you know, anesthesiologist voices can get loud when they need to, you know. And so that I would say, from my anecdotal experience, these numbers make sense. So we're talking about somewhere between 70 to 90% of surgeons and anesthesiologists, particularly women, and particularly racialized folks, will have experienced microaggressions on a regular basis. That's sort of where the numbers are sitting in terms of what we have from the literature. And I think you're absolutely right that there's this tendency to be like, oh, that's just a joke. That's the culture in the or. That's how we talk to each other. That's our banter, and some of that is true. And we need to have fun at work, and we need to have Joy at work and banter and joking around with one another is absolutely part of that. But there's a very fine line, I think, between that and when it tips into these potential impact and harm. Microaggressive types of comments.
[00:12:35] Speaker B: You also talked about the power differential that happens in ORs. You know, whether you've got learners, trainees, you might have healthcare professionals that are supporting, let's say the surgeons and the anesthesiologists.
What can one do? First of all, I guess one is to recognize it as you're suggesting. So certainly reading up and educating yourself.
But what, what is the, I guess the immediate action realizing, as you said, sometimes it's about not really like, you know, maybe they're not dealing with the systemic issue yet, but there's something happening in front of them. What would be your general approach to advising, you know, a surgeon or a trainee, for example, who is either experiencing it or is watching it, seeing it happen?
[00:13:17] Speaker A: Yeah.
[00:13:18] Speaker C: So I think recognizing it, of course, is really important.
The next part of what do we do is actually a lot more nuanced and complicated than we think. I used to be very much of the, of the view that, well, you have to say something, right? You see it, you have to say something.
But the power dynamic in the or, particularly if you're a trainee, can actually be very challenging. And not only are trainees in this sort of very hierarchical environment, and I'm not saying hierarchy is a bad thing, Right. Hierarchy sometimes is actually exceedingly important, especially when we're in the middle of something emergent, but there is also not just a hierarchical environment for that trainee, but an evaluative one. Often they're being evaluated and graded by perhaps the staff person in the room.
I would say, though, that if you do have positional power, then calling it out in the moment as much as possible is the way to go.
Shame and blame very rarely lead to transformation.
That has been my experience.
What I think is helpful is to name it and to try and bring some curiosity around it. Obviously, if it's egregious, we have to just cut it off and shut it down right away.
But to say something like, oh, I'm curious as to why you would say that.
You know, in my experience, that can sometimes land as X, Y and Z. In my experience, that can actually sometimes cause impact to people, that can be harmful. In my experience, that actually is reinforcing a stereotype about X, Y and Z community. That is not true. And that's not what we want to do. That's not who we are in this institution or in this or as people.
And then to sort of follow up with what you would like to see in this or, or in this institution or in this team. You know, we're going to do our best to pronounce everybody's names correctly. That's really important. And it's, it's part of who we are and how we make everybody feel that they belong in this or. We're not going to assume people's abilities and we're not going to assume somebody's lazy because they need extra breaks. We don't know what everybody's circumstances.
And then there may be a conversation that happens later, right? There may be like a brief conversation that has to happen in that moment, and then you may want to follow up with that person later.
There are situations where responding in the moment may not actually be appropriate and can sometimes actually cause more harm.
And certainly clinical situations where our attention needs to be completely focused on the patient. Right. Like something acute might be happening, we need to do that. But following up afterwards and following up both with the person who received the microaggression to say, hey, I saw that, I heard that, I noticed that. How can I support you?
And then following up with, you know, where that came from is really important. And there are situations where learners or others may say, I actually don't want you to say anything about this.
And again, we have to kind of. We have to walk alongside that person in solidarity and be like, okay, well, what can we do? How can I support you? My door is open.
The last thing I'll say about this, because it's really quite nuanced and we could talk about it for a long time. And I don't, I don't think we have enough time to really dig in, but there are some frameworks out there which actually lay out how you might respond in the moment. Because what we also know from the literature is that when you're in the moment, that sort of visceral, emotional part of you takes over. And it's very difficult sometimes to know what to say, even for us as fairly senior folks.
And so one of the frameworks that we present is from a paper that we reference in our narrative review, and we actually lay out that there's a mnemonic owtfd, and we actually lay out how you might want to respond in the moment. And some of the nuances around whether responding in the moment or responding after is going to be the right thing
[00:17:07] Speaker A: for that context, well, that's really, really important for us to understand that whole framework. And I would just suggest we have often a lot of senior registrars, residents listening in, and they can be very helpful to junior trainees, medical students, et cetera, in these situations by coming alongside them after the event and just telling them, I heard that. I understand it might be helpful.
And I'm going to. Perhaps I might consider on how. How to alert the residency director or a mentor to let them know that this is happening with this person, that they might.
They might consider a conversation in an evaluation environment.
[00:17:54] Speaker C: Absolutely. Because I think people often feel very alone, Mark. Right. Like that's part of what happens, that these things are happening very regularly and in of themselves, they seem pretty innocuous. But when they're happening all the time, you know, and nobody's coming to you and saying, I heard that, like, that wasn't okay, it can be very isolating. And then we get some of those things that we talked about before, like the burnout and the isolation and all of those kinds of things.
So, yeah. And I think, you know, one of the things that we're doing at our institution is working very closely not just with our lead residents. We actually do a workshop on microaggressions for them, and they do cases and work through this and do role plays, but also doing that with, as you say, our program directors, our faculty, because often faculty feel stuck. They're like, I know this is not okay, and I don't actually know how to approach it. So I think some of that continuous professional development for those of us who are in these supervisory roles is really essential. And I find role play in case studies and actually practicing it like a skill, just like we practice our clinical skills, is what we need to do. Because it's not going to feel easy initially. You're going to feel awkward and clunky, and you're probably going to make a mistake. Mistake. And that's all part of the course, just like it is when we're learning our clinical skills.
[00:19:05] Speaker A: Right. And I just. A personal note. I had a very powerful interaction very early in my career as a senior resident when I said to a female medical student, something along the lines, I can't remember about her size or strength or something, and she gave a very unemotional response.
You're evaluating me something to the effect of. On a physical characteristic I can't change, and it doesn't feel very good. And I remember that to this day, and it has very much shaped my whole thoughts about women in orthopedics.
Thankfully, she spoke up and it made A powerful impact on me. So I would encourage students, junior residents, please, if you can muster the, The. The calmness, give. Give a measured response of that, doesn't that. I don't appreciate that that's helpful to people.
[00:20:03] Speaker C: Yeah. And again, I think I tell learners, and you're absolutely right, like, have some of those phrases ready and available to you, because it can be very challenging in the moment when you're having that visceral response.
And for us to recognize that when somebody is responding in this sort of calm, anchored way, there is a lot of emotional work and emotional labor that has gone into them getting to that point. And this has happened to me multiple times. Multiple times in the AWA where, you know, I've been told that I come across very calm, very centered, and it's like, you know, the duck underneath the water, right, with the feet pedaling, and my heart's racing. And, you know, and it still happens even now. And, you know, I've been a consultant for over a decade, and I still have those moments. So I think.
Absolutely. And for us to recognize that it takes a lot for somebody to show up like that in that moment. And so the fact that you remember that, Mark, I think is a testament to. To that. To that learner. And hopefully they. They're listening or they know that that had an impact on you.
[00:21:02] Speaker B: And I wonder, just before we close out here, Saru, I wonder, Mark, in that situation, you know, whether it was the first time she's had to say this, whether it's. I'm guessing it's many, many times, or maybe like in many things, you know, it said to you so many times that eventually you say, okay, at some point I have to either find a pathway or say something. And. But it's incredible, I'm sure, that. That I have to believe, Saru, that for someone in her situation, it would not have been the first time that she would have heard something like that. And good on you, Mark, for, you know, make. Taking it and, you know, having it reflect on it. Because I think a lot of us just saying, oh, well, you know, it's fine. You know, you move on.
And I think that's. That's the difference. And I think us on our end doing more of that work, I think the work is on both sides, isn't it? I mean, so much of it is us also trying to understand, learn and. And continue. And on that note, you had you've referenced a narrative review that you've done. Is there any other important reference you would recommend? And we'll be sure, as Mark suggested, to make sure as part of the podcast we provide that note or that link to that particular paper and or review that you suggest we.
[00:22:11] Speaker C: Yeah, I do really like the paper where we took the framework from and it's referenced in our, in our narrative view. And I can certainly send it, send it to you, but I think there's something about having an anchoring, something to anchor yourself upon. Right. It's not dissimilar to when we're in a crisis situation and we're anchoring into our ACLS algorithms. And, you know, there's something really, I think, helpful about that because again, people often don't know what to say or what to do. So I would say that one, there's a number of other references in our narrative review which I think are helpful and I'm sure certain papers that have come out since. But again, I would just emphasize that this is about practice. It's about understanding the power in the room. It's nuanced and contextual. So, yes, we can have these frameworks and they're really helpful and we're going to have to adapt it and we're going to have to, as I said, realize that we're going to get it wrong sometimes and that's okay.
But I think again, really understanding that you don't have to have mal intent in order for impact and harm to occur. And I just feel grateful that you're here having this conversation with me. As two very senior leaders in orthopedics, I think you're role modeling what we need to do and how we need to move forward. So I'm very grateful for that and I'm happy to have been in conversation with you this morning.
[00:23:23] Speaker B: I would say on that note, both of us are equally grateful to you for providing the insight. And I absolutely Knew, Mark, some 25 minutes ago that you and I were going to come out different and learn some stuff. And we certainly have. And thank you, Saroo, for once again providing considerable insight to the work that we're trying to do, but certainly to the work that you've already done. So thank you and have a great day.
[00:23:44] Speaker C: Bye. Thanks a lot.
[00:23:46] Speaker A: Thank you, Siru. I'm glad I came to school today.
[00:23:49] Speaker C: I hope your case goes well.
[00:23:50] Speaker A: Yeah, thanks.
[00:23:52] Speaker B: Cheers.
