Chapters Transcript Video Putting Cultural Humility Into Practice Putting Cultural Humility Into Practice Originally Broadcast: Tuesday, March 1612:30 PM - 2:30 PM EDT Hello and welcome. I am Chauncey Watson, associate director of HIV marketing at Gilead Sciences. And on behalf of Gilead, I would like to welcome everyone to our first blueprints for Success Training Institute for 2021. Today's program will look at the importance of delivering cultural humility in the face of an increasingly racial and ethnically diverse population, where stigma and implicit bias continue to keep people out of care. This is the first in a four part series of our blueprints for success training institutes for 2021. We hope you have been able to join us for some or all of the previous training institutes. I would like to briefly go over our agenda for today's program will have 2 20 minute presentations and 1 45 minute workshop. Our first presentation will be given by Dr Elizabeth Kuzma and is entitled The Quest for Cultural Humility. The Missing Link in the HIV Care Continuum. Our second presentation will be given by Dr Darrell Wheeler and is entitled Putting cultural Humility into practice, redefining assumptions through knowledge and self reflection. And then lastly, you will have a great workshop led by our community liaisons looking at the centrality of listening and building empathy. Afterwards, you'll have an opportunity to come back and gage in a panel discussion as well as audience Q and A from each of you. Well, you have a chance to ask our faculty questions directly on today's content. Please click the button below your screen to submit any question at any time throughout the program. Today's program will be moderated by the incomparable Dr David Malebranche, Dr David Male Branches, an internal medicine physician and an HIV specialist in Atlanta, Georgia. He has specific training and expertise in men's health, correctional, health, student health and Brace to Inequalities Within medicine, as well as the prevention and treatment of HIV and sexually transmitted infections. Dr. David Malebranche is passionate about community engagement as well as outreach and has appeared in a video series. Ask the HIV Dot, which promotes education and empowerment on HIV prevention and treatment, and Revolutionary Health, which is a weekly YouTube live health Web series that is a part of the Counter Narrative Project, an advocacy organization for black same gender loving men. Without further ado, please allow me to introduce Dr David Malebranche. All right, Thank you Chauncey. Um, good afternoon, everyone. Or good morning to some of you. If you're on the West Coast, I want to thank Gilead and particularly chancy for inviting me to help moderate this session. Uh, we have some amazing Panelists today, and we have a whole series lined up in front of you that I think is going to be absolutely amazing over the next few months. So please, if you're watching now, look out for us in the next few months, as will be having additional sessions, really digging into cultural humility and how that impacts and how it's such an important part of what we do, uh, in our HIV practices serving our communities of people who are living with HIV. Our first presentation today will be given by Dr Elizabeth Kuzma. Dr. Kuzma is a clinical assistant professor at the University of Michigan School of Nursing in Ann Arbor. She is an expert in providing holistic trauma, informed primary care with cultural humility, including health promotion and disease prevention, management of minor, acute and chronic conditions. Dr. Kuzma is committed to working with vulnerable and underserved populations and is actively involved in and committed to professional and policy advocacy. Now I'd like to turn it over to Doctor Kuzmin for her presentation. Thank you very much, Doctor. Male Branch for that kind introduction. I'm really excited and honored to be here with all of you and with my renowned co Panelist, Dr Wheeler, presenting on this important topic today. Um, so to begin, let's start with a review of some key concepts so we can all be on the same page, beginning with culture. So what is culture? Culture is defined as the customary beliefs, social forms and material traits of racial, religious or social group. It includes the characteristic features of everyday existence, such as values, attitudes, goals and practices shared by people in a place or time. For example, popular culture, Michael Wheeler said Culture is dynamic, not static. There is no one size fits all model theory or process. Individuals vary tremendously within cultures but are all shaped by their cultures. Different is simply that different, Freya Stark said. The portions we see of human beings is very small, their forms and faces, voices and words. But beyond these, like an immense dark continent, lies all that has made them both of these quotes beautifully describe how each of us as individuals are different and unique. Though influenced by the world around us. In our culture, culture has many aspects, both visible and invisible, that shape how we view ourselves, how we view others and the world around us, the visible portions of our culture, our how we see each present ourselves on the outside. Or as Freya Stark said, The portions we see, such as how we dress the holiday as we celebrate or the music we listen to the invisible parts of our culture are all of the pieces of culture that lie underneath and have made us who we are our values, beliefs, feelings, assumptions and even in some cases, our privileges. Think about an iceberg. What you see above the surface is a fraction of what lies underneath. Now that we have a shared understanding of culture. Let's talk about the application of cultural understanding or sensitivity and healthcare by talking about two more key concepts. Cultural competence and cultural humility. A common term which you are likely familiar for learning about and understanding culture of others is cultural competence. It is the respectful and effective response of individuals and systems to people of all cultures in ways that affirm the worth and dignity of individuals, families and communities. Another term for what you may or may not be familiar is cultural humility. Is that a term that you've heard of before? If not, it's okay. I will present some information to help you understand the concept of cultural humility. Cultural humility takes cultural competence a step further. It entails an ongoing commitment to self reflection into creating beneficial and non paternalistic relationships. It is a journey of ongoing lifelong learning without a final destination with cultural humility. Self reflection is key. So take a moment to think about what is my cultural identity? What are my beliefs and how do my identity and beliefs impact how I interact with others? This is particularly important in healthcare, when our interactions and personal connections impact the health and well being of the patients we care for. Michael Wheel are sad. Cultural competence is about the head, whereas cultural humility is about the heart. As we move forward, I will explain that a little further. So let's take a deeper dive into the concepts of cultural competence and cultural humility. By discussing the goals, values, shortcomings and advantages of each. The goal of cultural competence is to build an understanding of different cultures to no more. This is accomplished through trainings and based on generalizations learned through research and other academic means rather than the lived experience. Gaining such knowledge lays the foundation to better understand the cultures. Others cultures more broadly and promote skill building. As Michael Wheeler said, cultural competence is the head. It is the process of gaining knowledge. In recent years, there has been a trend to move away from the idea of cultural competence and shift to cultural humility. As a newer concept, cultural humility is founded on the understanding that while you can learn facts about different cultures, everyone expresses their cultural identities differently. And not everyone within a certain culture adheres to those cultural norms. Beyond learning about other cultures. Cultural humility requires individuals to develop a deeper understanding of their own cultural identity and beliefs and how those beliefs impact our interactions with others, particularly as health care providers, how they impact the patients we care for. When thinking about these two key concepts cultural competence and cultural humility, think about the perspectives each represents, including Who is the expert in the room, and I will explore that in the next slide. Cultural competence implies that you can truly know another person's culture through learning specific facts or learning culturally specific perceptions of prevention, causes of disease, models of care, um, of health care practice and other dimensions. It's this idea that you are competent. You have achieved an endpoint. You are now an expert, while cultural competence trainings are good starting points because they can help you learn general concepts and different cultural norms in and of itself. It is not enough to develop a deeper understanding of our own identities, culture and beliefs. We must perform thoughtful self reflection to examine our internal biases, explicit and implicit address hegemonic assumptions or social norms and unlearned stereotypes. Cultural humility, as opposed to cultural competence, is a lifelong process and commitment to learning, growing and self reflecting, as well as working to address innate power dynamics. This is why Michael Wheeler defines cultural humility as the heart as healthcare providers who care for patients with cultural humility. We know that while we may be the ones who are experts in our particular health care, field that our patients are the only true experts on themselves. Their identity, beliefs, values, attitudes and cultural practices. So we have much to learn from them, as they do from us. And to be clear, cultural humility is not prejudiced. Exclusion, intolerance, discrimination, stereotyping, labelling, judging, bullying, etcetera. Yeah, a polling question should now be popping up. Um, so please take a moment to complete the pole. I will continue presenting, and after a minute or so I will share the results with you. Cultural humility can be a much needed path to equity. Think of cultural humility as the bridge between cultural diversity and social justice. Beyond creating an awareness and appreciation of cultural diversity. Cultural humility also offers a window into understanding social justice and the need for equity. Using cultural humility as the lens through which we see the world, we understand that not everyone enters the world on equal ground. If all aspects of a person's identity are valued and the individual is made to feel empowered, this is a step toward treating that person justly. This, in turn, is a step toward creating a broader equity whereby everyone is treated justly and can participate prosper and reach their full potential in society. Mhm Moving on to the U. S. Demographics. Um, the US demographics are shifting, which is in part associated with global migration. The Institute of Medicine's Global Migration Indicators 2018 report is a snapshot of what we know about migration today. Migrant categories include labor, migrants, international students, displaced people and refugees going a little further, while the U. S population is becoming increasingly ethnically and racially diverse and the minority segment of the U. S is projected to become the majority by 2040 for people of color are still face structural and systemic barriers to accessing healthcare in the United States. In 1998 Melanie Ter Valon and Jan Murray Garcia recognize the changing demographics of the U. S. And asserted that there is a need to ensure that health care providers have the tools needed to skillfully and respectfully negotiate the changing racial and ethnic diversity of the United States. To acknowledge and better understand the present, we need to remember and learn from the past. The US has seen decades of unequal distribution of wealth, which is rooted in slavery. It is also very important to acknowledge the historically traumatic relationship between medical institutions and the African American community, which has led to a lack of trust and research, public health and other health professionals in the community. A notorious case was in 1932 syphilis study at Tuskegee Institute, where black participants were misled about the study, and we're not given penicillin to cure their syphilis, even when it was accepted as a standard treatment. The study was eventually terminated in 1972 40 years later, after media exposure and public condemnation. But it wasn't the beginning or the end of medical mistreatment of black Americans. In addition, there are impacts from stigma emanating from some religious beliefs. Religious communities could foster moral judgments towards people living with HIV and AIDS by promoting negative attitudes towards the disease and those affected. The negative attitudes fostered by some religious communities echo the sentiment of the early epidemic days in which the disease was associated with sinful behaviors. HIV stigma among healthcare professionals that identify themselves as religious can include blaming and judging people living with HIV and AIDS. Additionally, there are structural barriers, including poorly funded educational systems, particularly the inequitable distribution of education funding. Beyond that, there has been a lack of comprehensive sexual health and relationship education, which is still a challenge face today, as many states and communities only require or allow abstinence only sex education. As we move on, I will highlight additional historical context and implications on current issues in health care. So to take a break, I'm going to go back to the question. Um and 3% said cultural competence, 22% said cultural humility, 72% said both and 3% said neither 72% said their organizations could improve on both cultural competence and cultural humility. All of the historical issues previously mentioned have been further exacerbated by the mass incarceration and criminalization of black men, the criminalization of undocumented immigrants and other significant barriers to healthcare access associated with high rates of uninsured individuals, health care provider shortages and reduced services, and lack of services such as substance use, prevention and treatment. Health inequities result from the co occurrence and combined effect of plagues among marginalized groups, which in turn drive higher rates of HIV, including stigma, silence and miss separation, public perception of lack of need, reduction of service availability, and support lack of awareness, prevention, testing and treatment and preventable HIV transmission. These all represent structural violence, which is the psychological or physical harm resulting from exploitive and unjust political, social and economic systems. Structural violence is a type of violence that occurs on a large scare scale by cultural institutions and systemic practices that perpetuate inequity and results in health disparities. For instance, despite having only 38% of the overall population, the Southern U. S accounts for about half of all new HIV diagnosis in the in the country and experiences more HIV related illnesses and deaths than any other region. This disproportionate burden of HIV in the South most adversely affects the African American community. In particular, black men who have sex with men currently face the poorest HIV health outcomes. Due to this very intersection of discrimination, stigma, poverty and other social political disadvantages, another polling question should be popping up. So take a moment to complete that pool, and I will continue presenting. Okay, so let's take a look at some of the studios D statistics based on most recently available data in 2018 from 2014 through 2018 in the U. S and six dependent areas and by region, specifically Midwest, South and west. The overall number and rate of persons diagnosed with HIV infection increased a year end of 2018. More than one million adults and adolescents were living with diagnosed HIV infection. Black Americans comprise 13.4% of the US population, yet have the highest rate and largest percentage 42% of HIV infections. The rates of HIV infection among African American women were 13 times higher than for white women and four times higher than for Latin X women. The Latino population made up 28% of new HIV diagnoses in 2018, but comprise only 18% of the population. The main HIV prevalence was 44.2% among African American transgender women and 25.8 among Latin X transgender women, compared to 6.7% among white transgender women. The largest percentage increase 24% and the number of persons living diagnosed with HIV infection was among the transgender women population. The largest percentage of persons living with diagnosed HIV infection were male. The largest percentages of HIV infections were attributed to male to male sexual contact, and 85% of all HIV transmissions among women were from heterosexual contact. Yeah, As we move forward, I will share some information with you about racial and ethnic disparities in HIV treatment and care. Based on a 2012 survey of 544 black men who had sex with other men, 29% of participants reported experiencing racial and sexual orientation stigma from health care providers. 48% reported mistrust of medical institutions, racial and ethnic disparities and health related outcomes among people living with HIV are well documented compared to other racial and ethnic groups. Black people living with HIV are less likely to be engaged in care to receive antiretroviral treatment and to adhere to antiretroviral treatment, all of which may contribute to their lower survival rates. Latin next people living with HIV are more likely to be diagnosed later in the HIV disease continuum with AIDS concurrently, resulting in greater delays in care, entry and anti retroviral treatment use. Okay, so the answers to the last question were that, um, stigma people voted. That stigma was the highest 44% silence and misinformation. 14 public perception of lack of need, 8% reduction of service, availability and support, 2% lack of awareness prevention, testing and treatment. 30% and preventable HIV transmission, 2%. So we're all over. But the big two areas were stigma and then lack of awareness, prevention, testing and treatment. Okay, back to the slide. Um, black men who have sex with men living with HIV experience stigma from health care providers, which was associated with longer gaps in time since the last HIV care appointment. L G B T Q. People, um, and people of color living with HIV where at least two times as likely to experience physically rough or abusive treatment by medical professionals compared to their white counterparts, less than half of Latin X people living with HIV are receiving medicine to treat their infection. And about three quarters of men who have received a script for prep pre exposure prophylaxis medication are white and only 9% are black. As we move forward, we will talk about how transgender people can feel shut out of health care. Many people in the l G B T Q plus community and that was living with HIV are vulnerable when ill or seeking healthcare services. That vulnerability is often exacerbated by disrespectful attitudes, discriminatory treatment, inflexible or prejudicial policies and even refusals of essential care. These barriers, in turn, can result in poor health outcomes and often have serious and even catastrophic consequences. Access to health care is a fundamental human right that is regularly denied a transgender and gender nonconforming people. Transgender and gender nonconforming people frequently experienced discrimination when accessing healthcare from disrespect and harassment to violence and outright denial of service. Participants in the National Transgender Discrimination Survey, a study conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, reported barriers to care when seeking preventative medicine, routine and emergency care or transgender related services, including widespread provider ignorance about the health needs of transgender and gender nonconforming people, which deter them from seeking and receiving quality health care. Data from the National Transgender Discrimination Survey suggests racial bias presents a sizable additional risk of discrimination for transgender and jen gender nonconforming people of color in virtually every major area of the study, making their healthcare access and outcomes dramatically worse. Now let's talk a little bit about some roadblocks to culturally competent care. Nursing and medical students report lack of exposure to cultural competence education during their training, especially in simulation and clinical experiences. Medical students receive an average of about five hours of content on cultural competence and l g b T Q health, whereas nursing students receive a meeting a medium of 2.3 hours. Okay, HIV work interacts with many attributes and behaviors that have been historically viewed as taboos as well as associated provider discomfort, bias, stereotypes, assumptions, discrimination, oppression, pathology, ization, criminalization, stigma, trauma and violence, including sex. So approximately 50% of practicing clinicians do not feel comfortable addressing sexual health with any patients during their health care visits, homosexuality, perceived hypersexuality, sexual abuse, sex work, poverty and drug use. Another polling question should now be popping up. So take a moment to complete that pole, and I will continue presenting. Now let's talk about some of the causes of HIV related stigma in health care settings. There is a general lack of awareness among healthcare workers of what stigma looks like and why it's damaging. Health care providers and staff may fear a casual contact with persons living with HIV and AIDS stemming from incomplete knowledge about HIV transmission. They may associate HIV with improper or immoral behavior, and they may make assumptions about clients based on their HIV status. Interventions must be focused on the individual environmental and policy levels. The individual level, increasing awareness among health workers of what stigma is and the benefits of reducing it is critical. Raising awareness about stigma and allowing for critical reflection on the negative consequences of stigma for patients such as reduced quality of care and patients, unwillingness to disclose their HIV status and adhere to treatment. Regiments are important for steps in any stigma reduction program in the physical environment. Programs need to ensure that health workers have the information, supplies and equipment necessary to practice universal precautions and prevent occupational transmission of HIV. The lack of specific policies are clear. Guidance related to the care of patients with HIV reinforces discriminatory behavior among health workers. Okay, see you. This slide outlines some practical steps that can be taken to help address stigma in health care settings, including making sure that forms, um, ask the ask questions about identity. Have some write an option so that people can write in their own gender, race and sexual orientation, making sure that the space created is accessible and comfortable with visual cues, showing that all patients are welcome, reflecting on how power structures are perpetuated through space design. So I always sort of think about how providers are often standing over patients, particularly in the inpatient setting. So maybe think about re looking at how providers and their patients sit. Are they sitting next to each other? Are they sitting face to face? Um, at the same level, training all staff. So includes support staff. Make sure that the janitorial staff also know about the availability of gender neutral bathrooms and cultivating a learning culture so that staff feel comfortable asking for training or information they don't know, so they can learn how to better meet their clients needs. Okay, so the answer to this last question, um, lack of diversity and healthcare leadership was ranked 18% systems of care not designed to meet the needs of a diverse patient population. 42% poor cross cultural communication between providers and patients, 8% lack of provider training and engaging diverse communities and care 17% patient fears and distrust. 5% ian cultural and individual stigma around HIV. Another polling question should be popping up, and I think this is the last one for my presentation. So take a moment to complete that, and then I will share the results after. Okay, So moving forward? Where does religion fit in? For many of us, religion and or spirituality are very important parts of our identities. However, we need to be cautious about how our own personal beliefs may negatively impact the health and well being of the patients. We serve some religious and our spiritual beliefs and cultures may underpin feelings and attitudes about sexuality, HIV and health care approaches. Focusing on spirituality can be a superlative means with which to approach uniquely marginalized and hidden populations such as racial and sexual minorities, and can provide adequate, culturally competent and culturally sensitive professional resources to assist persons struggling to bring in to sink their sexuality and spirituality. This slide outlines some basic terminology to help you understand some key concepts that impact overall access to health care and the associated outcomes, some of which have already been presented, including ageism, ethnocentrism, sexism, cultural competence, health disparities, stigma, cultural health, intersectionality structural violence, cultural humility and racism. And these are things that you might want to take a closer look at a later time moving on. We also need to talk about how language is really important, when, when caring for patients with cultural humility and creating safe spaces, The People First Language describes a method of speaking that tries to avoid perceived and subconscious dehumanization when discussing other people. This going to be applied to any group that is defined by a trade or condition rather than being defined first and foremost as a human being when it comes to illness and health issues. Putting the person before the diagnosis describes what that person has rather than what they are using. A sentence structure where the person comes first allows for this, for example, saying people with disabilities is more humanizing than saying disabled people or the disabled. Now let's talk a little bit more about language, some dues and don't this slide outlined some very important tips and key information to help you all with language. It has a nice side by side comparison to outline some terms to avoid and highlights more respectful language you can use because of the clinical history of the word homosexual. It is aggressively used by anti LGBTQ plus extremists to suggest that people attracted to the same sex or somehow diseased or psychologically emotionally disordered notions discredited by the American Psychological Association and the American Psychiatric Association in the 19 seventies. So please avoid using homosexual except in direct quotes. Please also avoid using homosexual as a style variation to simply repeat, avoid the repeated use of the word gay. The same goes for homosexual relations relationships, homosexual couple homosexual sex. These phrases are frequently used by anti LGBTQ plus extremists to denigrate L g b T Q plus people, couples and relationships. As a rule, try to avoid labeling and activity, emotion or relationship as gay, lesbian, bisexual or queer, unless you would call the same activity, emotion or relationship straight if engaged by a heterosexual. In most cases, people will be able to discern people's sexes and orientations through the names of the parties involved, depictions of their relationships and your use of pronouns. Remember, there is no single l g b T. Q plus Lifestyle L G B T Q plus. People are diverse in the ways that they lead their lives. Using such phrases denigrates L G B T Q plus people and suggests that their sexual orientation and gender identity is a choice and therefore should be cured. Notions of a so called homosexual agenda are radical rhetorical interventions of anti LGBTQ plus extremists seeking to create a climate of fear by portraying the pursuit of equal opportunity for LGBT plus people as sinister. LGBTQ Plus people are motivated by the same hopes, concerns and desires as other everyday Americans. They seek to be able to earn a living, be safe in their communities, serve their community and be able to take care of the ones they love. Their commitment to equality and acceptance is one they share with many allies and advocates who are not. L g b T Q plus. I'm going to go back to the pole that you just completed, Um, so some of the options, um, that people answer to 26% including right up right in options on forms, 48% said creating an accessible and comfortable space, 17% said evaluating how power structures are perpetrated through space design, 59% said training all staff, including support staff, 58% reported cultivating a learning culture and other for 8% Okay and moving on to the last slide. As we wrap up, here are some things I want you all to keep in mind. Cultural humility is a lifelong commitment to self evaluation and critique. To redress the power imbalances in the provider patient dynamic and to develop mutually beneficial and non paternalistic partnerships with communities on behalf of individuals and defined populations. Some examples include if a client identifies their need for prevention medication, a provider has a due diligence to gather enough information, including sexual history, to adequately assess the clients. Overall health and treatment needs not every woman who has sex with men identify as heterosexual. That assumption may adversely impact the patient's care. Another example is stay up to date with new biomedical interventions and their reception in different communities. Thank you very much for listening to my presentation. Now I would like to turn it back over to Dr Male Branch. Dr. Kuzma, thank you so much for that amazing presentation. I was actually taking down notes, Um, while you were talking, I just thought so much of the stuff that you brought up was so relevant. Um, I want to remind our audience who's watching to make sure you ask questions, and you could submit that. So any questions that you have, either for Dr Cozma's presentation that came up or as we go forward into Dr Wheeler's presentation, please put them in now, um, as they're on your mind. And then that way we'll be able to get back to him after the breakout session. I do want to mention Doctor Kuzmin. You said something that was very interesting about the language, and I thought about yesterday I was actually in clinic and two things came up. One. I had a young patient who was taking prep, and he actually had, uh, in his electrical and electronic medical record, the I C D code that we have to build in order to provide services and get coverage from insurance. The I C. D. Code used was labeled high risk homosexual behavior, and I actually mentioned to it, mentioned it to him, and we laughed and kind of talked about it about how crazy that was. But it speaks to what you were saying about these systems having to really change what they're doing, and that includes going into the electronic medical record and including people's pronouns and their sexual orientations and gender identity. So all the stuff you were talking about was amazing, and I really loved the part of your discussion about cultural humility and cultural competence not being opposed, but necessarily parts of the same body or parts of a continuum that work together. I think some people try to throw out the cultural competency baby with the bathwater, and it's just like, you know, you don't really have to do that. I think it's all part of a continuum. So there were a lot of great lessons learned that you gave us, um, so thank you again for that great presentation. And now, without further ado, we are going to move into our next presentation by the illustrious the esteemed, the amazing and phenomenal Dr Darrell Wheeler, the provost and senior vice president of academic affairs at Iona College in New Rochelle, New York If you can see, I'm kind of, uh, using my my verbal talents to kind of hype Dr Wheeler up, although I don't think he needs any other hype man with him his reputation precedes him. Uh, Dr Wheeler is a highly respected scholar who was published and presented extensively in the areas of health and mental health disparities. HIV prevention and intervention. Minority health, individual and community resilience. L G B T Q community health and intervention. Social Justice and community Service. Uh, he's a longtime friend and colleague. So without any further ado, I'll hand it over to Dr Wheeler for his presentation. Okay. Thank you very much, Doctor. Male Branch, I think. But I'll deal with you later on that one for that introduction. It is really a pleasure to be here. I think it's still morning in some places, Afternoon and others, but what a pleasure to be here. And Dr Kuzma, that was phenomenal. Kudos to you. What a great opportunity to be here. So I'm going to pick up on the theme that Dr Michelle Branch and Dr Kuzma just did. And we in this segment of the presentation, we want to talk about putting cultural humility into practice. And as we move into our next position here we talk about the many components of identity. I want to talk about the application a little bit from a 30,000 ft structure. And that is that our systems of healthcare are actually part and parcel of a medical apparatus structure that in many ways is flawed. And it's flawed because of some of the contextual historical. And a seed is that Dr Kuzma presented and in this segment, what we really want to talk about our ways in which we deconstruct those and then construct them in a more useful and helpful applied environment. So when we think about the components of identity, there's racial and ethnic. Race and ethnicity are often conflated, and they're not the same. National origin, language and cultural, sexual identities, sexual practices, practices and identity not being the same. Always family structures, religious and spiritual manifestations and residents locations. So one of the things that will do is we go forward is we're going to ask you a poll question, and I think that should be coming up now. And it looks to with which, which with which of the following do you most closely identify? We'll come back to the results in a little bit. But as we talk about understanding cultural approaches, one of the things that we have to suspend is a binary way of thinking that there is a right or wrong culture. Lives within a context and context can value different elements of being. So if we look at this slide, we see that cultures that have a, um, uh context where there's a high business outlook tend to be cooperative. Those with a high work ethic or relationship oriented, Um, those with a work style that's more team oriented, value high context contrasted to environments or cultural understandings that are more individualistic, where it is the individual that manifest the power or manifest the ability to direct style and engagement in work. So considering these, it's really important to think about where you are in your own ability to understand your cultural approaches, because sometimes the difference between what we see with our clients or patients is that it rubs against something that we have felt is very important to our own lifestyles. So our going into our next discussion point we look at an example in this particular example is actually an oversimplification, and I have to make that commercial break right there that when we we do exercises and we talk about groups we're talking broad sweeping generalizations. But when we think about interpersonal styles in this particular example, we know that some cultural groups value consensus of the WE compared to personal opinion of the eye. And it's important even think about these words, consensus and we personal opinion. And I Some of us learned this. When we talk about, you know, everyone has one kind of a mentality. We all have personal opinions and personal views, but sometimes those rub against the collective understanding and in certain groups and in certain cultural experiences. It's really important to understand that the group consensus is more powerful and more desired than just the individual cultural individualism, which we often see in the United States experience. And our next experience on this really looks at key components of a cultural identity, individualistic level of identification and language abilities. So individual characteristics, ethnic and cultural references. How do I see myself as a person from an outward manifestation may appear to be African American, but maybe I came from a Caribbean background or an African background, so my ethnic orientation may not fit the mold that my outward manifestation would seem to lead me to be identified with, especially to the untrained eye or ear. What's my level of identification? Do I identify with both cultures, whether those cultures or racial or ethnic or geographic location do I see myself as an urban dweller when I'm living in the country? And therefore I'm having a Green Acres moment where I really can't identify with the farm community around me, and it's It's stressing my system out and language abilities are we multi lingual and multilingualism is not just about what the American, um, psyche might call foreign languages. There are different ways to communicate and are. We talk about language and code shifting and being able to talk at different levels. So what I what I might say and practice on a screen today may be very different than something I would practice and communicating with my family. And so these language abilities are really important, going to take a quick pause here and just look at some of the results that came back from the first poll. And 46% of us identify our ethnic group. Race or ethnicity is number one, followed by national origin, language and culture is number two and rule versus urban is 4% and family structure and religion and spirituality are equally at 10% and sexuality at 9%. As we go forward, we look at some of the content on our levels of engagement around our identities, and it's important for us to think about how the levels of influence impact our identities. Individuals are shaped by yes, they're they're individual resources that they bring with them and their understanding of those. But they're also influenced by interpersonal interactions. Community and organizational engagement And yes, by policy policy can either liberate or constrained policy sets rules. Policy often sets means of access. And so it's important to understand that our levels of influence and how an individual is engaged with his or her larger environment is a result of a multilevel approach. It's it's inadequate to see the person solely as an individual or even just in relationship to his or her family, without understanding the many elements that impact the factors. So I could use Dr Mel Branches example from earlier looking at the electronic health record of a patient, he and the patient, or having an interpersonal interaction. But it could be the policy from using the I C D codes or some other standardisation within the health informatics system that attributes a certain label. And that's driven by organizational and policy consideration. So there's a lot of interplay that goes on and understanding not only the individual patient or client, but also the ways in which we can seek to create environments that better serve our patients or clients. So as we go forward and look into new ways in different ways of understanding, let's talk briefly about concepts again that Dr Kozma brought up. And those are spiritual and religious. Now, one of the things I've come to critique about my own approach over the years in HIV prevention and particularly as we talk about scientific and biomedical approaches, is that biomedical and scientific approaches are very important. But they live within a gestalt or psyche or a shared experience that include non biomedical components, which can be equally as impactful in the ways in which people access and use services. Here. An example is religious perspective, where some might see um, HIV as a message from God. Um, others can see it as a consequence of supernatural activity or witchcraft. or sorcery juxtaposed a biomedical approach, which is virus causes the disease. And in fact, understanding how individuals can bring to mutual agreement or engage with these two diverse perspectives may give us new insights on ways in which we assist our patients and our communities to integrate the best of biomedical within religious and spiritual practices. So again, on this particular note, it's valuable for us to see the world not from a singular silo. But oftentimes there is a blurring of the silo and as part of a home, a static home, a static exchange of content and ideas in a dynamic framework. And we, the providers, those of us who are engaged in those of us who are seeking to transform our communities and our work environments have to bring these perspectives together. And as we go forward and look at other elements in terms of complementary and alternative medicine, I'm drawing from the last slide. We see that here is a great place for us to think broadly today about ways in which people choose to use medicines, how they become connected to therapeutic practices, why alternative practices that might be critical to cultural engagement and thinking on that continuum, where that we is more important than the eye that being involved in holistic treatments that bring me in relationship to others in my community is more valued than individual practices, and many cultures actually are able to coexist along with biomedical practices. So when we look at cultures from, for example, in the South Carolina low country, the Gullah community, which are direct descendants from the African slave trade and actually over the years created enclaves that have held onto many of the traditions have found meaningful and impactful ways to do this. And as we see as we go through our various discussions today and move forward, we see the opportunities in which we bring these complementary pieces together and start to understand. As Dr Kuzma said, before that, dimensions of the sexual self are not just siloed, but they actually blend together to create the unique experience that each individual holds about their sexual Selves. This includes the identity. How do you consider yourself, How does your patients, your client, what see themselves, what are the words that they use to describe themselves in both relationship to others and how they differentiate from others. What are the behaviors in which they engage? Some of these may be sexual behaviors, but they're also behaviors of affinity and affection. Are they openly comfortable engaging in behaviors? Are those more difficult for them? But again, behaviors and identity can be synchronised IQ, or they can be out of sync. They can map onto the same labels, but they don't always have to, and the same goes for attraction and desire. And when all three of these are considered I liking, I liken it to a key and a lock relationship. If either provider I am not using the right key in the lock, it's hard for me to open the discussion with my client because I've made assumptions based on labels that I hold, as opposed to engaging in a more holistic and client centred approach. As we'll see as we go forward. Some of the ways in which we need to consider this and the first and most critical point I would posit, is being able to listen. Listening is such a crucial component in this work. If we're not listening, we're not able to avail ourselves to this narratives that the patients are giving us how they refer to themselves and very often cues that can be used to assist us in helping our patients and our communities develop plans of care and treatment that are truly theirs and sustainable over time. How do we display policies back to the context component? Um, where are they? Are they written in ways and presented in ways that provide access to multiple groups? Um, don't make assumptions about how L g b T Q. People consider themselves make structural changes where appropriate and where possible. Um, making single stall, unisex restrooms available Recognize that self identity may not correspond to behavior. As we said in the prior slide. And as we'll see as we go forward, there are other ways in which we kind of see the cultural humility and what it entails and cultural, human, military and practice. I really focus, um, for today's discussion on the first or the lower um, quote by C. S. Lewis, which says, What you see in here depends a good deal on where you are standing. When I hear that phrase, I think about that phrase and relationship to my position, al itty with the individuals with whom I am working and it is important for me to know where I am standing, and I don't mean just physically standing, but in its totality, where my status, where my power differentials rest where my cultural lenses are blinded. It really impacts the way in which I interact with others, because what I hear and see is ultimately always filtered through my own lens. And I have to be in a constant, lifelong process of engaging my own cultural lens to be, uh, present in the moment and try to live these attributes of cultural humility. Doing this work is work, and as we see as we go forward, what you start to recognize is that there are activities that we can do to help increase our own self awareness. Do I provide all patients with the same needs the same information, tests and treatment? The body of literature in health care delivery would suggest that that is not the case in all situations. Some of this is contextually driven in terms of times and demands. Some of these may be temporally impacted in terms of where you are on a given day and the many pressures you face But others are based on assumptions that we hold about the person based on ad parents. They may be based on my own personal views and influence. So again, where I stand is critical and is my interaction with my patient a partnership between equals and we'll talk about this a little bit more as we go forward and look at some other activities. As I said, this is a commitment to lifelong learning. This is not a one stop. I'm done. Fill up the gas tank and I'm gonna run forever. Even your gas tank if you use the car and the gas enough well at some point, need refueling. So it's not very different. With cultural humility, we have to know the history and culture of the client groups served. Conversely, I would say that we have to know our own history, um, too often in the Americas and the Unite or should say in the United States, we operate out of a historical or a cultural framework that culture and history do not matter. I think our current political environment is calling us to task on that. We have to understand how these factors may influence behaviors and perceptions. Are we being motivated to keep acquiring knowledge? What are our internal incentives? It's not always about an external incentive. What drives me to want to do this work and then taking in new information. It is about the information loop. I can reach points of information overload, or I can meet points where information is just coming at me and I'm not ready or receptive to engage in it. And as we look at um, future elements that help us to do this work and going forward on this process, we really see the patient has to be at the center of what we're doing. Are we willing to listen? That theme of listening has come up more than once in the presentation that I'm doing here, and that's not by accident. The capacity to listen is not as simple as we assume, because listening requires that we are actively bringing in the information, holding that information sufficiently long to make sense of it, based on where we are at that moment in time, and then we're able to make a response to it in the American in the U. S. Culture in the Western European culture What we find is there is a positive of listening. Um, I'm in the New York area and have spent a lot of time in the New York area over the past 25 years. Um, what we find in New York and when I think anthropologists have done great work on this the listening or pause time, the time in which you're filtering the information for certain groups. If it goes more than a minute, it makes others uncomfortable. And some communities that pause time is essential to showing deference and respect that you've actually digested. It's like a good meal. You want to sit with it long enough to enjoy it. But here on the East Coast and some other communities, we have what we call a negative pause time where you're already you formulated your response before the person speaks, and as the person speaks, you're giving them your thoughts on what it is they're telling you. Thus, you cannot have actively listened. And so this is what we're talking about when we're practicing cultural humility. Are we putting the patient at the center and are we being willing to listen, to understand, to respect? That is more than just a minor activity. And as we'll see as we go forward, there are elements of this that play into our ability to practice. You're gonna get, I think, another poll after this slide. But what does cultural humility mean in practice? Is it about acknowledging that the patient patient is a combination of intersecting identities? Many of those we want? No. Until we listen and talk to the patient, trying not to get distracted with what's in my head about what I think you need to know what's uncomfortable for me. You heard Dr Koosman talk about the fact that many, even medical providers are not capable or comfortable or asking about and exploring basic sexual practices with their patients. So is that because it's uncomfortable to me in a professional level? Why is that? So is there anything you think I should know as a question of engagement and recognizing that the patient ultimately is the expert on his or her life? We'll come back to this slide, but we'll go forward and look, um, and we'll learn about those responses shortly. Institutional, cultural humility. If we think about the sociological slide from earlier we think about the levels. Um, it is important to understand that institutions manifest a culture that can be driven by policies, practices and individuals. And so each of us who works for an organization or within an institution can probably point to attributes of that institution that relate to the institutions culture and conversely or by additive. In this discussion, I would say those are the points where we want to think is my institution culturally, Um uh, humiliate, uh, cultural humility Is cultural humility a critical part of my institutional environment? Oftentimes, when I see the words humble humility and humiliation, I have to think out loud my head. Remember, they all have the same base word, and it's very easy to go from humbleness to humiliation, um, in our actions and and so even with that stumble there, I'm reminded that that those three h is and militarization here is really important because there are times in which we think we're being equipped. But in fact we can, as was pointed out earlier, use terminologies, quote unquote homosexual in a way to describe something which is not a ref, which is which is not showing cultural humility. But it could be a form of humility, hating a person or denigrating a group. So we want to create a mission statement within our institutions. Is our mission sufficiently embracing cultural and linguistic competence? Did we devise strategies that are consistent with that mission that reach out to patients and groups and allow us to do this work? Do we develop non discriminating, an inclusive, all embracing policies and practices? These first three require constant review because times change situations, change language, changes, modes of delivery. So once again, creating a culturally humble cultural humility within our institutions is not a one and done scenario. And as we'll see as we go forward, you really start to get this when we take an example. So let's take this example. And let's look at the case of a young black dancer who identifies as gay and tells his case manager that he's been having questions about his gender identity. And here I do believe you'll get another poll. But before we go to that poll, let me, um, come back and look at the poll responses to the prior question about where your institutional your organization is. Um, 1% said not at all. 25% tries, but does not succeed. Um, 45% say yes, somewhat. Well, um, 21% say yes very well. And eight, 8% say yes. Extremely well. So those folks who are in the yes, very well and yes, extremely well, when we do the question in response, the sharing of your insights will be very helpful for how your institutions and organizations have done it. But here on this particular side, the the young black dancer, you know, as a case manager, how do you respond? Do you ask what have you been experiencing that leads you to feel this way? Do you talk about this in terms of, uh, your own training? After today, do you start to explore ways of giving information about hormones and gender affirmation surgery? Or do you engage and and ask the person if he wants to join a peer mentor relationship group for gender non conforming people? It'll be interesting both to see the responses, but also in our question and response period to think about the things that drove us to those responses in relationship to our patient. Let's look at another example, though before we go forward. Um, and here again, I think we're going to get a poll response. But we have a young Latino man. He's married to a woman with two Children, has been diagnosed with HIV and comes to your clinic for his first visit. He hasn't yet told his wife about his status. How do you respond? How do you respond? Respond in a way that is demonstrating your cultural humility and and putting the patient at the center to assist in addressing the needs that this patient brings to you at this moment. So again, we'll come back to your responses, but we'll go forward with our next few slides to get us back on time. The provider. You could have responded. You know, the clinician asked, How's he coping with HIV? The clinician advises him that he should disclose his status with his wife. The clinician speaks to him about treatment and prevention options as well as refers him to for counseling. Do note. The one thing we don't have is all of the above, because in some instances it's not an either or, but it's a win and, um timing issue because maybe all of them are appropriate. But it's important to ask that, um, let's see. I think I see some of the responses, but I'll have to move my, uh there. Okay, um, 75% on the first poll said the case manager should ask, would ask, What have you been experiencing that leads you to feel this feel this way? 1% identify the gender affirmation surgery and 24% of the peer mentorship group. Let's go and look at our next slide here and look as we come to a close. I think I have two more slides here. What is shared decision making? I've mentioned it early earlier, but it's really important to think about both the definition and the practice of this shared. Let's deconstruct this shared decision making. Making is a Jaring. It's an active word decision is the action, but the making of that demonstrates its dynamic nature. Decisions lead to actions, and the shared component of that requires the mutuality. It requires that you see the person as an equal in his or her decision making that you understand that it is a collaborative process. It provides patients with the support that they need, but it enables them to act and to make the process of making and decision, which will drive activities for that patient and hopefully, better outcomes. So those three small words carry with them a lot of weight in terms of mutuality, the act of coming to a decision that should include information, but the process of making maybe very much driven by relational aspects and you understanding key elements of the patient's life. And as we've discussed in this segment, the ways in which the multiple contributors to cultural identity play in two things that you can use in the making aspect of the decision that is a shared process. And as I go to my last slide, I just want to really reinforce some of the things that we've talked about here. A person's identity has many components. A person's cultural background may inform their behavior. Behaviors are the outward manifestation of many things. Individuals are shaped by many aspects of their social environment. It's not just internal religious and faith based views may play a role or part in an individual's response to HIV. Um, sexual identity behavior and desires may not always align the key may not fit in the door in a way that makes sense to us on first glance, and that cultural humility involves standing in the patient shoes. Where are you in relationship to being able to understand these And before I turn it back over to the one the only the phenomenal, stupendous Dr David Mill branch. Um, let me just come back to the polling items. The clinician ask him how he's coping. 37% selected that the clinician advises him, that he should disclose his status to his wife. 3% there. And 60% says the clinician speaks to him about treatment and prevention options again, a diverse set of responses. A lot of this will depend on where you are with the patient. Equally, though, is where you are with the comfort each of those selections you select at that moment. And the question that I would posit is, why do you make that selection and have you actually listen to the patient in a shared decision making process? So on that, I think I've gotten to the end of my presentation, and once again I turn it over to the one the only the phenomenal. The man of the hour. Dr David Malebranche. Thank you so much, Doctor Wheeler, I really appreciate you giving me the flag back that I gave to you at the beginning of this of this session. Um, and I really appreciate your presentation coupled with Dr Cozma's, because there's really some amazing information where we kind of pare down. And I can tell you as a clinician that last question that you had, uh, it's basically you do all of the above, but it depends on what order you address them in. And so for me, if I could answer that question, I would say I start with the coping. How are you talking about the individual? How is he coping with it? And then you can branch off to the other things. But all of those components, um, will stimulate some wonderful discussion. One of the take homes I got from you was about the fact of listening. And we do have a study from the journal General Internal Medicine that said that doctors interrupt patients a median of 11 seconds into their clinical visit. 11 seconds. So I want people to take that home and take home the point about listening, being very important. And in the spirit of this whole presentation and what we're doing today being a microcosm of a of a clinical visit, we have a certain amount of time, but to unpack all these things, we've gone a little bit over, um, because it takes time, but you're you're supposed to finish things up in a fixed time, but in order to move us forward, we're going to go into the workshops now. And all of you who are watching should have received a worksheet. Be an email earlier today that will be used in the breakout session. And if not, we'll provide a link in a link to the worksheet and each workshop room. So right now, please click on the button on the lower part of your screen right now to join the workshop breakout sessions. All right. Welcome back, everybody. And I hope, uh, you had a good breakout session. I was able to grab some food in the meantime, so that was helpful to keep me awake and my blood sugar levels elevated during the next 20 minutes or so. So we are going to open it up for questions. Um, and I want to remind participants to please submit your questions via the button on the bottom of the screen on the screen. And questions will come to you one at a time via the chat function. Um, I'm sorry I was reading something different. Um, so I'm gonna start actually with the question to both Doctor Kuzmin. Dr. Wheeler, I do think we talk a lot about barriers and roadblocks and obstacles a lot. I'd like to flip that on its end and instead of deficits, talk about assets. So I would like to throw out to both of you while we're getting other questions from people in the audience. Um, what do you see As kind of some of the concrete solutions. Maybe audience members who are clinicians, um, or working in the field and public health. It's already playing. We're just a Q and A in 22 minutes 22 minutes. Um, what are some of the solutions that you can think about with regards to how we can better develop our clinics and really employ cultural humility and cultural competence? That whole continuum, um, into our practices? Doctor Kuzmin, start with you. Sure. Thanks. Um, I think there's a lot of different ways and things that we've brought up in the different presentations as well. But I think taking the individual level of personal ownership, like attending trainings like this, learning about different language that's helpful and language that's hurtful, Um, thinking about how can you, as a clinician in your space, have forms that are more inclusive? You know, sometimes that can be a challenge in bigger health systems. But are there ways that without having a long term process going through legal, that you can have a form that you have your patient fill out when they walk in the room? And they can fill out their pronouns and their preferred name and their gender identity and their sexual orientation? I think it's also important to have in your clinical space you want to have your patients feel represented. So what what is in the actual waiting room? What are the visual cues that people see? What are your brochures and handouts that you give? Um, so different individuals from different cultural identities feel represented, feel welcomed? How does your your staff, um, welcome and treat people when they come in the door or they call the space. So I think there's lots of different things you can do at the individual level and how you provide care in your clinical space. But then also using your knowledge and skills and position as a clinician to try to advocate for system wide change as well. How about you, Dr Wheeler? Sure, I would certainly agree with Dr Kuzma. Mhm. Surely I would encourage, particularly within your organization. ALS. I'm setting to do a walk through analysis kind of what Kurt Lewin might talk about when you talk about project management and there are a couple of fundamental questions you wanna ask and walk through. What are the touch points with the patients? Because these are the places where you start to identify where cultural humility engages with the patient. And then the second would be to ask the question. Are the touch points driven by immutable factors such as some rigid policy or governmental thing? Are they low hanging fruit? So I think Dr Kozma just gave a couple of great examples, and then the third bucket would be those buckets of things that will take a little bit more work the final thing you need to do in the walk through and looking at those touch points and in order to do those three points is to ask yourself fundamentally, what is the change that I want to happen as a result of doing anything? So if I add a same gender bathroom, what am I trying to accomplish? It's not just about making the patient feel good. If the patients at the centre, though the patient feeling welcome, is a part of it. How does that relate to? Because the patient came to you, not for their best buddy moment. They came for you, to you, for quality care, in the context of a place that cares for them. So those have to come together because you can have all the colorful, lovely stuff you want and have poor patient care. And that's not gonna help. I think that's an excellent point. We have a comment from Eric's Eckmann, who basically says My thought is gender should be a write in for everyone, as it is others who write in, unless we all do. What are the Panelist thoughts with regards to gender being a write in? I don't see that as a problem. But in in our culture it's going to require a lot of work to educate people who have never thought about the question. And you're gonna have to ask yourself, Are you ready to do that level of work? Because you have to do it for every person who's never thought about what they're gonna have a male or I'm a boy. I mean, you don't know what you're going to get. Mhm, Doctor, What do you think? Yeah, I would agree. I think, Um, fundamentally, I think it's a good idea that makes it like you're treating everybody the same that they can feel it in. It's not just making a space for someone who doesn't identify as the list that's provided, um to write in, but I do agree. There is like a socialization that has to come when you do make changes like that, Yeah, and I think it's going to take time for me. It reminds me of taking a sexual history to and from traditionally back in the day. They used to say, you know, ask questions. Are your sexual partners men? Women are both and then you know that kind of morphed over into saying, Tell me about the genders of your sexual partners and who are the genders of this? What are the genders of your sexual partners? And then let them tell you. So I think you can start with the institution and being able to say What is your gender and having them right in? I do think it's going to take some time culturally, not only on a small level in clinics but also as a larger culture, particularly in the United States. That's more culturally repressive when it comes to sexuality, to get people out of that binary box where it has to be men, women and then other. And then you feel like you're excluded because you're putting something other, which is a little bit strange. But I think over time we'll get to that. There's another audience question. What is the best way to educate a co worker who is not being culturally confident or even outright offensive? Is it best to speak to them directly or with the supervisor? This sounds like a question almost that you have to those forced videos that you have to did you have to watch as part of your training. What do you both think of that? It depends on the context if you are in a situation where you were there when it's being said, and you can maybe take the person aside and say, Tell me about this comment that you made or what does that mean? Or why do you think that and then kind of switch? You have to be cautious that if you confront someone aggressively, they'll become defensive and almost like shut off. But if what they were doing was overtly harmful to patients, I think that requires higher level intervention. What do you think, Dr Wheeler? No, I certainly agree that it depends on the context, but it also depends on the relationship you have with the person that you're responding to. Um, because you know, if you're observing something from someone who in the context, who is a supervisor to you, that may warrant 11 approach as opposed to someone who's a collateral or a co worker of yours. So let's not be naive to think that all settings are equal, so I appreciate the question and it's an aunt, and I think it requires some attention to the setting in which you are doing the response. Yeah, I would agree completely, and I think a lot of times and help professional schools, and I can speak to my experience as a medical student and a resident. Previously there is that hierarchy. So if it's your attending physician that is saying something offensive in that moment, and your evaluation is based on what they assess of you. People are scared to vocalize that. And I remember a situation in New York City as a resident where we had a Latina woman who was coming in for chest pain and she had some cardiac disease. But she was inoperable. She couldn't have a coronary bypass. And so they were just treating her with medications and the, uh, his cardiology fellow who came in. And he basically spoke to the whole team, which was a diverse group of racial and ethnic backgrounds. And he said, Well, you know, yes, she has real disease, but there's also a component of hysterical Hispanic syndrome, and I remember I was like, I sat there and we had a sister from Brazil. We had a sister from Mexico sitting in there. They didn't say a word. I went to him outside afterwards, and I kind of let him have it. And he was embarrassed, like I took him to task about it and how he could be stereotyped. And I said, There are two Latino women in the office that was tremendously offensive and he went back and he apologized to them later. But I think that I was a second year resident at the time, and so I had a little more. But when you're a student, it can be really, really problematic to do that. And so I think, you know, there's moments you can do at that at that time. You don't have to call him out in front of everybody, but you can make it. You pull them to the side, and then there's kind of the later conversation where you can change some of the systemic stuff. Um, but some people just have to be taken to task, and you have to let them know at that moment, because if you miss that teachable moment, um, they miss it and then they just keep going on. All right, let me move forward with another question. I'd love to hear what the Panelists think about how they think cultural humility relates to providing post exposure prophylaxis to a patient who shamed himself for his sexual behavior and how professionals using de stigmatizing behavior can make a difference. Start with you, Dr Customer. What do you think? Okay, I think that's a really excellent question. So thank you for whoever the question is from, You know, I think it's you always just have to remind the patient that we're all human beings and we aren't you. You have to remind them not to blame themselves. We all, you know, make different decisions in our lifetime, and being exposed to something does not necessarily mean that it's their fault or their problem. That's sort of like the historical context, right that comes into play, um, and that you can still provide the medication and help them be as healthy as possible. Um, so I think it's really trying to address some of that internalized stigmatization that's happening and let them know that that's not how you feel and that they still deserve access to care and the medication. Yeah, I would add to that. I remember a student that I saw University of Pennsylvania when I was working in their student health center and they came in and they really were holding their head down the whole body language. They came in from post exposure prophylaxis. And he said, Doc, I really messed up and, you know, I had unprotected sex and I looked at him and I said, Oh, you had natural sex And he immediately like, looked up and he was like and I was like, Natural sex is without a condom. Condoms are unnatural. So stop beating yourself up. Let's talk about this and we kind of went in. And the surprise on his face because you could tell he had already seen providers with, like, beat them down and made him feel awful about having sex without a condom. And we need to talk about how sometimes a lot of you know heterosexual privilege is that heterosexuals a lot of times get to have sex without condoms. Um, and nobody really pathologize is them. Whereas for LGBT is kind of a double standard with it. Um, what do you think about that, Dr Wheeler? There is certainly a double standard. And in the good old days, of HIV work. When we talked about, you know, eroticized sing safer sex. It was we had more fluid discussions. I think about what you just described, as, you know, natural sex. Um, with meaning barrier less sexual engagement preceded all forms of barrier methods. And so we've got to help people to have a dialogue about what it means to have healthy sex. Because you're confronting, as you astutely identified, not only the the use or non use of the condom, but we're actually confronting the pathologies around sex in our culture, which applies to heterosexuals and two non heterosexual, um, folks across a continual a very large spectrum. And I think we do our patients and our community is a disservice by thinking that they can't walk into them at the same time. People can have what we call condom less sex or barrier list sex, um, and still look out for their sexual health. And that's part of their sexual health. So being able to do that and then being there to say, Hey, if you're concerned about STDs, I can test you. If you're concerned about HIV because you know where you live and you know there's a high prevalence in your area, then we can work on that. All right, so we have an audience question specifically for Dr Kuzma this as I was interested in the definition of cultural competence and cultural humility. While I consider myself culturally competent, I also realized I'm not an expert by any means. I see myself in an ongoing cultural humility process, which is what you talk about, that I'm not sure I have a question, but I feel that I have a grasp on both concepts. Do you feel that there's more to add to this? I think that that's a pretty adequate representation that, you know, getting cultural competence is that you go to trainings and you learn about language and cultural norms. But then cultural humility is sort of reflecting on that your own beliefs. And then how does it interact with what you've learned about other cultures and individuals? But then also sitting across from that individual patient and saying, you know, I have these things that I've learned about different cultures, but that could mean something totally different to you sitting across from me, and so I have to open myself up to learn from that person sitting in front of me. That's a great response. Um, I'll also I'll direct this next question for Dr Wheeler. Cultural humility can be labor intensive emotionally. It requires a lot of intention and reflection. How can we support our colleagues as they practice cultural humility so they don't burn out? Because there's not. There's already enough, uh, pressure in clinical scenarios to burn folks out. So if we're adding something additional with cultural humility, how do we ensure that people don't burn out? So the one thing you can never guarantee that the other person won't burn out because it's it is individual work. I think the first thing that we have to do is if I'm on a cultural humility journey myself and this go. This is similar to the question that you just ask Dr Kuzma. If I'm on the journey, then I have a way of demonstrating and my colleagues that the journey is one step at a time. But it's a forever kind of a journey which normalizes the fact that I don't have to consume it all and be expert. I think that that contributes significantly to the burnout because people are underlying. The question about burnout in this particular work is Have I finished it yet? Have I gotten enough of it? Am I demonstrating? And And those are the questions of of someone on a journey of cultural humility, which is not about a destination, it's about continuously refining your journey. So I think I guess that's a long way of saying First, absolve the person of a need to get to an end point. But to be open and engaging in the process helps to reduce the sense that I have to accomplish it like a letter grade on an exam. It was anything to add. Yeah, I just wanted to add that I think that that's an very specifically challenging situation for us in healthcare, right? We have this weight on us that we have to be experts right on all of these different things, and we have to know, and we have to be confident and so to be humble and have humility and to acknowledge that we don't know everything is a challenge and can be an emotionally, um, draining situation. But I think just like with anything in health care, whenever we have a new patient that we're going to see you. You enter each patient's room with an open mind so you don't like no matter what happened five minutes before or the 10 patients who saw that had something similar. Every single patient is unique, and you need to come in with a clear mind. And so you sort of approach cultural humility in the same way I think those are excellent points will feel two more questions. Then we'll start to wrap up. We've got about seven minutes left. Um, so an audience question. Can the Panelists address how to manage microaggressions in the workplace? Um, I think we could probably start with the definition standard definition of what Microaggressions are and then tackle the question. How do we how do we manage them in the workplace to either of you? So by definition, microaggressions are the partners to the earlier question. Is that what do you How do you respond to somebody who's being hostile? Microaggressions fly under the radar of being covert. That the kind of thing that you catch a whiff of something, but you're not sure it's actually there in the ether. That's probably a sign that it's a micro aggression. It's not me coming to your face and calling you a bad name or like the example you gave Dr Mill Branch so that that is how I operationalize the microaggression. But it does result in a person having a sense of not being fully valued, respected or engaged. And to you, Dr Kuzma, how do we manage it So we know it's there or we've we've witnessed them occur and we see this as kind of a culture where there are micro aggressions, they're allowed to fester. How do we manage that? I think that's a harder question to address, I think, if you, you know, like um, Dr Wheeler said, it's this sort of subtle thing. If you're starting to notice a pattern, maybe that is depending on the relationship of the person that you take them aside and talk to them about it. And maybe they don't even know they're doing it. You know, sometimes they can be intentional and sometimes unintentional, But maybe that's like a bigger question of if it's becoming a pattern. If it's more than one person, if it is clearly bothering someone else, maybe we do need to sit down and have some trainings and talk about these different things and how it impacts individual, Um, our colleagues or patients, you know, the environment that we're in. But I feel like maybe Dr Wheeler Doctor, Male Branch, You have something else to say, But I think they're harder to address because of, like, they're so much more subtle. Yet they're still sharp. I don't And I think you know, just to that question, just remember that I think those microaggressions probably have as much are a greater impact than the overt aggressive behaviors because you're not able to give it a name immediately. And so those are the ones you sustain repeatedly. Yeah, they're kind of like little sharp knives, um, kind of cutting into the flesh if you want to make that analogy. And someone astutely mentioned that micro aggressions have a macro impact on the person, and I've heard a lot of people actually say they want to do away with saying like a implicit bias versus over bias microaggressions versus macro aggressions. Just call it bias or just call it aggressions and then kind of work for it, because the level or the severity of it is really, um it's subjective to who is experiencing it. And so that's a That's an interesting concept there, as far as you know, being intentional about what our position Haliti is and who's around. So for our final question from the audience and thank you all for asking these questions, can you describe white fragility and discuss the best approach for providing cultural humility When training health professionals, you smiled. Go, Doctor Kuzma, Uh, that's the white lady on the panel. No, take that. What? You know it is real. It's like having these conversations people automatically, like, put up their wall like, Oh, I didn't do anything. Oh, I'm not trying to offend anyone. And Eric, you have some really great questions. I just have to say So thank you for those. Um, I think it's similar to all of these conversations with Microaggressions. You know, you really just have to take it on up front. And when I if I have conversations with people related to this, you know, I always just try to say like I'm human, I'm not perfect. I'm always I know I'm going to make mistakes and often not know that I'm doing it, but I'm open to learn. And if somebody has a perspective that is different than mine, I need to hear it and break down that barrier. And not and again, it's sort of like who has the power and who has the expertise in the room. It's like if you're telling me something's bothering you, I need to put down my barrier. It isn't about me, it's about you. And I need to hear what you have to say so that we can make this a better situation. And I would just I would just add to that with regards to the definition. I think the question of her, uh, the fragility part, the fragility part comes into play, as the name implies that somehow by to confront it there, there's a risk of breaking the thing. And what happens in terms of white fragility and practice is that we over extend an accommodation not to confront the extreme the person, because we don't want them to break into pieces. So recently I was in a situation where, um, someone talked about, you know, aren't we very happy that now these issues that are coming forward on social justice are being elevated and people can get the services they want. I said Whoa, stop a minute. The very same people that you're talking about have been saying this for not just since George Floyd, but for hundreds of years. But now that you've acknowledged it and you're ready to embrace it, we can have the discussion. But before it pushed your boundaries and your sensitivities to, we couldn't have it. That, to me, is a manifestation of white fragility because it was accommodating to not pushing the boundary, but only at the point of acceptance by the presumptive majority. Were we able to have the dialogue. So I I think there's a personal and then the macro in the context. Yeah, I co signed on that. And I think one of my colleagues at Emory Division of General Medicine, Dr Kimberly Manning, who's just a beast with narratives and doing cultural humility and telling stories in order to prove those points. She made a comment. I told the story about a non black colleague who said, Oh my God, this anti racist training, this cultural humility, enough already. It's so much I'm so exhausted from it and they were so tone deaf, and her comment in the story was, How do you think I feel that I'm experiencing this every day as a black woman? If you're exhausted, I'm exhausted. So I think people have to step out of the shell like, Dr Smith said, and just realize it's not about you at that point. That's basically the essence of what cultural humility is, so we'll end on that note. I just want to remind everyone who is participating. You will receive a short follow up survey. Please complete the survey because your feedback will help us improve the blueprints for success. Virtual training institutes moving forward and, in addition, to receive a certificate of attendance, as well as a tool kit that includes key takeaways from the program and where to look for additional information. If you complete all four programs, you will receive a certificate of completion for attending the Blueprints for Success Virtual Training Institute series and I will mention to everyone Remember, this is a series. So the next program in Gilead is the Virtual Training Institute. Series will be on the topic of stigma and implicit bias on Tuesday, April 6, so please mark your calendars again. I want to thank the illustrious and amazing Dr Elizabeth Kuzma and the wonderful and phenomenal Dr Darrell Wheeler for their time, Um, and disseminating knowledge with us today and thank you all for joining us today. We will see you on April 6. So please join us then. Thanks again for attending. Yeah. Thank mhm. Created by
