Be Woke, Choose Growth

Gender

Sexism is alive in medicine, including the field of psychiatry. Dr. Reshma Jagsi and colleagues published a study in 2016 on sexual harassment in medicine. She surveyed 1,066 recipients of career development grants (K08 and K23 awards) from the National Institutes of Health. Ten percent of men reported experiencing gender bias in their careers, while two-thirds (66%) of women reported experiencing bias. Most of the female survey respondents (92%) had experienced sexist remarks or behavior, 41 percent experienced unwanted sexual advances, and 9 percent experienced coercive advances in their professional careers.⁵

Turning to psychiatry, although increasing numbers of women are going into the specialty, a gender gap remains. At the 2021 virtual American Psychiatric Association meeting, Dr. Marcia Unger chaired a panel called “Triple Threat: Young, Female, Professional – The Experiences of Young Female Psychiatrists and Psychologists.”⁶ The panel discussed several challenges affecting women in psychiatry, including salary differences, harassment, parental leave policies, microaggressions, and lack of mentorship. The panel referenced a 2018–2019 report⁷ that indicated 17 percent of female faculty in academic psychiatry have experienced gender-based disrespect compared with one percent of male faculty. At the 2020 virtual meeting of the American Academy of Psychiatry and the Law (AAPL), Dr. Ariana Nesbit-Bartsch chaired a panel on behalf of the Early Career Psychiatrists Committee entitled “Beyond Yoga: Tips on Work Life Balance for Early Career Psychiatrists.”^8,9 During the discussion on finding balance in academic psychiatry, it was noted that women are significantly less likely than their male counterparts to advance to a rank of professor.¹⁰ As indicated above, the number of female psychiatrists is growing such that currently 42 percent of psychiatrists are women, yet women only make up 9 percent of psychiatry department chairs.¹⁰ Reasons for this may include differing responsibilities and roles outside of the workday, part-time work, parental leave, limited role models, and a lack of mentoring.¹¹ Gender-based discrimination is also an important consideration when analyzing this disparity.

In forensic psychiatry, gender bias may manifest in a variety of ways that affect training and professional involvement. In their presentation on women in forensic psychiatry at the 2018 AAPL meeting,^12,13 Drs. Kelly Coffman and Helen Farrell discussed how gender bias might affect opportunities for forensic exposure in residency, as well as acceptance into forensic fellowship. They also discussed how forensic psychiatry is at the intersection of multiple male-dominated fields, thus potentially discouraging women from participation. If access to forensic psychiatry training is potentially affected by gender bias, then it follows that the potential for female leadership in forensics may also be diminished. The AAPL website lists 48 U.S. fellowship programs and eight Canadian programs for a total of 56 forensic fellowships. Based also on the AAPL website, about 11 of those 56 programs have female program directors with a handful of female associate directors associated with other programs. The number of female AAPL members has increased over the past two decades¹² from 10 percent of AAPL membership in 1994, to 25 percent in 2004, reaching 35 percent in 2018. On the other hand, AAPL began in 1969, and it was not until 1991 that Dr. Kathleen Quinn served as the first female president.¹⁴ There have been seven female presidents to date, out of a total of 48 presidents, with four of the seven being in the past decade.

We need to effect change so that women trainees can thrive in their future forensic psychiatry careers. In our training programs, we need to increase both mentorship and sponsorship of promising female trainees so that they achieve merited positions of leadership at their institutions and within AAPL. We need to address institutional policies and practices that negatively affect women, such as the gender pay gap and parental leave. We also need to change the cultures of our training sites and professional organizations to eliminate microaggressions and gender-based practices that hold women, and particularly women in caretaker roles, back from success. Finally, there needs to be zero tolerance for sexual harassment. In his August 10, 2021 resignation speech following allegations of sexual harassment, former Governor of New York Andrew Cuomo said “I didn’t realize the extent to which the line has been redrawn.”¹⁵ The line has always been there; the question may be the perspective from which one is viewing the line.

Race

In their June 2021 Journal editorial “Charting a New Course for Forensic Psychiatry,”¹⁶ Drs. Gary Chaimowitz and Sandy Simpson wrote eloquently about the forensic psychiatrist’s ability to provide insight into key structural differences in society and the use of those insights to improve the lot of our fellow human beings. They challenged us to become advocates who call out systemic racism, stigmatization, and discrimination. In addition to using our unique vantage points to diminish inequities for our patients and evaluees, all levels of racism need to be eradicated from our teaching institutions and from within our own organizations. Further, we all have to engage in doing this work to avoid the pitfall of the “minority tax”: placing extra responsibilities on minoritized individuals to address problems of diversity, inequity, and racism in our organizations.

At our training sites, diversity needs to be part of our recruitment strategies. Education on topics of social justice should be incorporated into general and forensic fellowship didactics, as we have sought to do locally. Training program policies should be scrutinized for both intentional and unintentional discrimination. In our professional organization, all presenters for our annual meeting should be encouraged to address racism and other social determinants of health and justice that relate to their topics. Like other organizations, AAPL needs to have cultural diversity within leadership from president on to committee chairs. Leaders should be sponsors and mentors of minoritized forensic psychiatrists looking to be involved and active members.

Sexuality

Those trainees who are considered sexual minorities (non-heterosexual people) have additional layers of stressors to deal with in forensic psychiatry. In our workplaces, which often have an unexamined heteronormative context, our future colleagues are making decisions about whether to come out in the workplace, to share an important part of their identity or keep it secret. While many may believe that sexuality does not belong in the workplace or training, hiding part of one’s identity may be a major stressor and diminish an individual’s potential.

Heterosexist environments can be stigmatizing and can produce a negative effect on the organizational citizenship behaviors of lesbian and gay employees. Research suggests that altruistic organizational citizenship behaviors of non-heterosexual employees can be predicted by being “out” in the workplace. As well, “stigmatization salience and organizational climate for heterosexism predict levels of workplace outness” (Ref. 17, p 321). Structural stigma against sexual minorities includes discriminatory laws, policies, and attitudes, and predicts adverse well-being and health.¹⁸ A recent meta-analysis considered the relationship between the disclosure of sexual orientation at work and individual, relational, and organizational correlates.¹⁹ Disclosure was most strongly related to the workplace’s organizational climate.

Another meta-analysis²⁰ noted that concealment of sexual identity affects all people who are of sexual minority. Panchankis and colleagues noted that “Concealing a sexual minority identity can simultaneously generate the stress of hiding, protect against the stress of discrimination, and keep one apart from sexual minority communities and their norms and supports.” (Ref. 20, p 871). Using 193 studies of over 92,000 subjects, the authors found a small association between concealing sexual orientation and internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating); substance use problems were less likely among those concealing. Further, they found that internalizing mental health problems were more strongly associated with concealment in studies that considered a lack of open behavior, that were more recent, and that involved younger participants. Based on what is detailed above, it is critical that our training environments and professional societies work to eliminate stigma against sexual minorities to create environments that support people being their genuine selves.

Wellness and Balance

Drs. Sutapa Dube and Andrew Levin of AAPL’s Trauma and Stress Committee wrote about “Physician Stress/Physician Well-being”²¹ in the September 2019 AAPL Newsletter. As they note, 300 to 400 physicians commit suicide annually. Suicide is the leading cause of death among male residents, and second only to cancer for female residents. Burnout is experienced by half or more of physicians. These are startling statistics, and this was pre-pandemic. Will Newman’s presidential year (during the pandemic) had a theme of physician wellness. We need to be woke to wellness to preserve ourselves, and to create a better professional life for the generations of forensic psychiatrists that come after us.

In recent years, the Accreditation Council for Graduate Medical Education (ACGME) has placed increased importance on wellness and burnout prevention. There is an entire section of the common program requirements on well-being and the word well-being appears 34 times in the document. There is a professionalism milestone specific to well-being in Milestones 2.0 that every general resident is evaluated on biannually. The ACGME even sends an annual well-being survey to residents and faculty. A quick perusal of the hobby sections in this year’s crop of Case Western residency application reveals that the ACGME’s emphasis is in line with the values and desires of today’s trainees. The future members of our field have invested many hours of training in meditation, mindfulness, and yoga. They’ve engaged in therapy and other activities to improve coping skills, set good boundaries, and engage in self-discovery. They have nurtured and tended to the aspects of their identities beyond medicine that provide them with rich, fulfilled lives. We fail them if we do not model wellness and safeguard it for them at our training institutions.

We need to reform medical culture that sustains unhealthy work expectations and stamps out vulnerability in learners. Simone Biles and Naomi Osaka have been wellness proponents in a sports culture that crushes young athletes. Similarly in psychiatry, we need to speak up for change. We also need to celebrate the things that enrich our lives outside of psychiatry. In our professional meetings, topics related to burnout and wellness should be viewed as of similar importance to the mechanics of how to perform an insanity evaluation. The aforementioned panel presentation “Beyond Yoga: Tips on Work-Life Balance for Early Career Psychiatrists” is one such example. The panel focused on wellness for early career forensic psychiatrists, including discussing resilience, burnout, peer support, well-being, balance in academic psychiatry, and private practice.⁹

In training and in professional forensic practice, we also need opportunities to process challenging cases such as those involving matters of trauma, race, gender, culture, and sexuality. It is important that senior North American leaders, such as Dr. John Bradford, come forward to discuss the stress-related potential negative outcomes of our work on our own lives.²² Locally, our fellowship has specific teaching sessions about burnout and stress in forensic psychiatry. Fellows discuss their stress and countertransference, a difference from the “stiff-upper lip” culture of the past. Many forensic psychiatrists find it healthy, years after training, to continue to process challenging cases with former co-fellows and other colleagues. As we go through the stages of our own lives and adjust our social identities accordingly, we may appreciate changes to our abilities to process and compartmentalize. For example, becoming a parent or elder caretaker might result in struggling with certain types of evaluations. Professional and personal contentment depends on our ability to be fully faceted with work and personal priorities in balance.

Looking outside of the United States, our Australian and New Zealand colleagues, as part of their continuing professional development (akin to required continual medical education) participate in peer review groups (PRGs).²²As described in the Professional Development Program Guide, PRGs “are small, self-selected groups of peers who meet to review their work in a setting that is organised to be supportive for individuals involved to present and learn from the presentation of work experiences and issues” (Ref. 23, p 15). Personal experience reveals that such PRGs can help support our own wellness and provide a confidential outlet to discuss complex or upsetting cases.

Summary

Being woke is about continuously searching for more understanding and truth, and challenging oppression and problematic norms in society. It is both an exploration of and an appreciation for intersectionality. It embraces balance and well-being. Efforts have been made in our field over the last decade to advance wokeness. The American Association of Directors of Psychiatric Residency Training has an active Allyship group and a curated list of antiracism and diversity resources and is dedicating the 2022 meeting to advancing diversity, equity, and inclusivity in residency training. AAPL held town halls during the pandemic to shine a light on diversity in the organization. WAAPL (Women of AAPL) meetings, along with the introduction of the Diversity Committee and the Women’s Committee, help tackle these concerns. These newer committees are building on the work by the Cross-Cultural Committee, Gender Issues Committee, and the International Relations Committee. They are seeking to create educational opportunities while providing mentorship and sponsorship. We need to work to ensure that those who may find themselves in the out-group are included at all levels, and that all of us are “baked in” rather than “bolted on” to the field and our organization so that everyone can grow and thrive. Change takes time and continual review to keep intention and impact in alignment, but we are making progress.

In summary, we hope we have made a compelling case to be woke and choose growth. Psychiatric training and professional organizations need to embrace woke culture and change to better understand the intersectionality of our practitioners, patients, and evaluees. We also need to consider the wellness and work–life balance of our trainees and of ourselves. Even though, as Nobel Prize winning Belgian writer Maurice Maeterlinck wrote, “at every crossroads on the path that leads to the future, tradition has placed 10,000 men to guard the past,”²⁴ we have great opportunity for positive change. Become your woke self, embrace change, and celebrate a better future.