At the 2023 Stanford Medicine Diversity and Inclusion Forum, speakers emphasized communication that destigmatizes the patient, empowers frontline workers and supports non-English speaking patients.
May 17, 2023 - By Emily Moskal
Kintsugi is the Japanese art of repairing broken ceramics with gold dust lacquer. The idea is to not only repair something that is broken, but to turn that imperfection into a strength. That’s what can happen when health care providers take aim at stigma, bias and inequity in the workplace and turn adversity into empowerment, according to Devika Bhushan, MD, former acting California surgeon general and keynote speaker at the sixth annual Stanford Medicine Diversity and Inclusion Forum on May 12.
“Any stigmatized identity or lived experience where you’ve really struggled … you end up learning so much about yourself,” said Bhushan, who has served on Stanford's pediatrics faculty. “The kintsugi is more beautiful in the end.”
At the forum, faculty, students, staff and community members gathered to learn how to become agents of change for diversity, equity and inclusion in the medical field. Held at the Li Ka Shing Center, the forum was largely composed of workshops developed by residents and fellows who participated in the 2022–2023 cohort of the Leadership Education in Advancing Diversity, or LEAD, program within the Office of Diversity in Medical Education.
Bhushan’s keynote set the tone for a series of hands-on workshops by emphasizing the necessary tools to craft clinical communication free of stigma, bias and inequity — whether the words are being directed at a patient or at one of the many overlooked frontline workers.
“Language that stigmatizes reduces any one of us from being a whole and usual person to a tainted and discounted one,” Bhushan said. “It involves labels and stereotypes and assumptions. It involves status loss and marginalization in systems and structures.”
Bhushan gave an example of stigmatizing language in a medical setting, citing words that cast doubt on a patient’s experience or that imply blame. For example, using the term “substance abuser” instead of “a person with substance use disorder” can cause clnicians to judge the patient as less deserving and to provide less adequate pain relief.
Bhushan cited a study that showed 80% of people experiencing a mental health condition said that the stigma and discrimination they felt was worse than the condition. When that happens, she emphasized, the barriers for patients seeking help can become insurmountable.
“There’s a 10- to 20-year life expectancy difference between those who have a mental illness diagnosis and those who don’t, and this has lots to do with embedded stress,” Bhushan said. “People are dying from cardiovascular disease, cancer, respiratory illnesses and more at much greater rates. It also has to do with the quality of care that’s received.”
Acknowledging the frontline
Frontline workers — such as interpreters, administrative staff and custodial staff — often feel overlooked and invisible, contributing to a decline in their mental health. But these people are the foundation of a well-oiled clinical enterprise. That was the foundation for a workshop titled “The Invisible Frontline,” identifying gaps in recognition for the contributions made by non-clinical workers to patient care and understanding the detrimental effects of hierarchies in medicine.
The workshop started with participants writing the names of people they work with on sticky notes, then placing them on a sheet with corresponding job titles. The activity’s big take-away: No one wrote down the name of an interpreter or someone in environmental services, more commonly referred to as custodial staff.
When reflecting on the assignment, one of the workshop speakers, Mario Hernandez, MD, an anesthesia resident, said that frontline workers are often made to feel invisible and inferior.
The next exercise focused on hierarchies. Participants were asked to group different roles in a clinical setting — doctors, lab technicians, project coordinators — based on the frequency that these groups communicated with each other. The results illuminated a large gap between frontline workers and clinicians.
Workshop speaker Danielle Macris Nahal, an infectious diseases fellow, pointed out that these associations are often based on hierarchy, which comes from a graduated level of supervision and autonomy.
“The voices on what’s often perceived at the bottom of the hierarchy are commonly thought to be less deserving of respect, and these voices are often silenced or ignored and thought to not contribute meaningfully to the team,” said Macris Nahal.
Acknowledging the work of frontline workers and finding ways to collaborate with them were potential steps forward that could lead to action, according to workshop participants.
Translating for competency
Many patients and their families are not native English speakers, a major hurdle in receiving a proper diagnosis and treatment in a setting where translators can be in short supply. That was the focus of a workshop titled “Not Lost in Translation.”
Margarita Ramos, MD, a speaker and pediatrics specialist at Children’s National Hospital, said that health care workers, particularly interpreters, can help create a safe, supportive environment by connecting the doctor, nurses and other workers to the patient and their families.
“A lot of patients that rely on family members to translate may not be able to maintain confidentiality, and this lack of access to translators leaves patients feeling vulnerable and disempowered because they’re not able to fully express what their experience is,” Ramos said.
The workshop had an opening activity in which one participant introduced themselves for 30 seconds and then another participant repeated what they said. Showing the difficulty of doing that in a single language helped demonstrate the difficulty faced by interpreters.
Ramos emphasized the overlooked nuances of semantics that imply judgment or stigma. Instead of saying that you will “use” an interpreter, the better term would be “collaborate with.” Using the verbiage “limited English proficiency” reinforces the idea that someone has a shortcoming — and contributes to a language barrier that is associated with poorer health outcomes.
Interpreters need to have a cultural competency — an awareness that their cultural values may differ from that of the patient. It’s a crucial component for providing both a pleasant experience and positive health outcome, Ramos said.
“We want providers to care for patients and build that therapeutic relationship, but we also want to make sure that patients are being understood and their safety is highly regarded,” said Lily Cheung, a panel speaker and Cantonese interpreter. “There’s a lot of opportunities for collaboration. I hope that everyone leaves here thinking that we are partners and collaborators.”
About Stanford Medicine
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