E28 Equity in Surgery with Julius Ebinu, Shahzeer Karmali, and Morad Hameed

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it. This is a very special episode of Cold Steel. The murder of George Floyd is yet another example in a very long list of visually disturbing interactions between visible minorities and authority figures in America. Well, heartbreaking in its own right, this event and the subsequent global social ignition that is followed has prompted a broader discussion on racial equity across society. This conversation is equally important within medicine and in particular surgery. We were lucky enough today to be joined by three guests. Morad Hameed and Shahzeer Karmali are friends the podcast and known to many of you. But we also have Dr. Julius Ebinu, who himself has an amazing story of migration as a teenager from Swaziland, Africa to Canada, just completed a PhD at the University of Alberta, a postdoc degree at Harvard University. And who has worked both previously in New York City as a neurosurgeon and currently in Sacramento, California. The panel’s comments on call for change our food for thought for all of us at a very deep level. Well, welcome to a very special edition of of Cold Steel, the surgical podcast. We thought given the intensity and the magnitude of recent events, not only in in the in the United States and Canada, but really throughout the world that we should probably address it and have a conversation. So we’re very lucky to have really four great guests, including Ameer who of course, US listeners all know. And our goal today was to talk and explore the concept of racial equity and in particular, how that impacts surgery not only in Canada, but also in the US. So maybe with that in mind, then Dr. Ebinu, we’re hoping that maybe you could give us your general thoughts on racial diversity within surgery as a whole. And in particular for our listeners, you know, as somebody who you know, spent the first part of your life in Swaziland, then moving to Canada, and now working in the US as a as a neurosurgeon.

Julius Ebinu  02:56

Yes, thanks. Thanks. Well, it’s obviously great to be here and to have this discussion, especially in light of what’s going on in our world today. More so here in the United States. You know, I think, as far as race goes, um, you know, it’s safe to say that, throughout Canada, and also throughout the United States, there’s steadily becoming an increase in the diversity of the population as a whole. And as far as health care goes, you know, it’s important when one considers health care delivery and health care disparities or equity, as it was, as it were, to ensure that that same diversity is reflected within the health care workforce. And, you know, I’ve had the privilege of, of training in Canada, and then working in United States, on the East Coast in New York City and now on the west coast, in Sacramento. And it’s been very interesting to me to see how there is diversity or lack thereof, both within the health care workforce, within the trainees that are within the system. And also, as far as the disparities within the health care delivery, to the patients that we see. So I think it’s an important topic to talk about, I think here United States, they have at least acknowledged that it is a problem. And you know, that disparity is more more apparent with the pandemic that’s going on right now. So, so understanding that it is a problem, acknowledging that is a problem and then sort of working towards some of those potential solutions to address it are all important within surgery and within health care as a whole.

Chad Ball  04:49

Curious, Julius, how has the pandemic informed or impacted this greater conversation on racial diversity specifically?

Julius Ebinu  04:58

Yeah. So you know, we’re noticing here United States is that more so the minority population, those of color, or other minority ethnic groups that tend to be more affected as far as infection, the virus and either be hospitalized and dying. And, you know, the question has become, you know, why is it that despite the percent percentage population of minorities in this in certain city, why is there a disproportionately higher amount of minorities being affected? And I think it, it really boils down to some of the systemic issues here with the United States as far as the health care system goes. And more so how health care is viewed in practice in the United States. And what do I mean by that? Well, you know, by and large, you know, as opposed to in Canada, health care is not accessible to all here United States. There are certain barriers that exist. And health care is for the most part considered a privilege, right. So the higher socio economic status you have, the more access you have, the more privileges you have, as far as your health is concerned. And that’s both in terms of preventive measures, as well as you know, treatment or surgical interventions. And so with this whole pandemic, what they’re realizing is those population groups that have not had that consistent access for reasons such as their socioeconomic status, are tend to be disproportionately affected by the virus. And I think it’s highlighting some of the inequities in the system as a whole more sorts of pertains to access to health care, and implementing some preventive measures that would render certain populations, you know, put them in a better in a better place to be resilient towards what’s fighting this virus.

Chad Ball  06:59

Now, it’s really interesting, um, you know, Shahz in Canada, both at the key and surgery forum level, as well as the Canadian Association of general surgeons, you’ve been a very vocal proponent. And I know, it’s certainly a passion of yours with regard to the concept of racial equity. And, you know, I’ve always sort of thought from afar that you balanced that very nice with gender equity most recently, in the last couple of years. How do you view this sort of whole topic from a Canadian perspective? And just for the listeners to know Shahzeer did spend a little bit of time in Houston training doing bariatrics. So he does have that American flavor as well.

Shahzeer Karmali  07:38

Yeah, so it’s very interesting topic, Chad. So you know, when we look at Canada, as a general, when you compare Canada, US, Canada is usually, you know, seen as a very diverse and multicultural population. There’s always this idea of, you know, almost almost, obviously a visual minority. So the difference between Canada and the US is idea that, you know, Canada, both this idea of multiculturalism, whereas the US is this idea of a melting pot, right? In the US, you all melt in your US first, right? Whereas Canada, you know, I’m an Indo Indo-Canadian, right, like, so it’s, it’s different, different ideas. So generally, Canada is seen as this kind of multicultural, diverse population, but when you kind of dig into it a little bit more, and you look at medicine in general, and is there is there diversity, really in medicine. And there was, there’s a really good article published in the CMAJ. And, this is kind of where some of the interest comes about by a person actually, that that some of us know as Moneeza Walji. So she published this idea on diversity in medical education and it delved into this idea of, you know, is there is there diversity truly in the medical system? And interestingly, you know, I, as an academic, I’m involved in, you know, medical school interviews and stuff like that interested in like, diversity isn’t really a question that’s asked, we don’t really ask students who apply, you know, what racial background, are you? I guess it can be taken either way. And, and the interesting thing is, so they, they looked at their studies, and, and what she did is they published idea of, like, you know, how diverse is his medical education? I’ll just kind of quote a couple things that she quoted. So, you know, we’re Canadian data, you know, we look at diverse minority groups, and so many groups like what I and Ameer represents, you know, and Morad, you know, South, Southeast and East Asians still actually really well-represented in medical medical schools. They’re tend to be, you know, within 30 to 40% of medical school classes, but there are other groups that are very underrepresented. And specifically, when we look at Aboriginal groups like they are ranking around 1.6%. And when you jump towards, you know, individuals who identify themselves as African or Caribbean, it drops to you know, 2 to 4%. So it’s very interesting when we look at diversity Canada. And this is kind of where my take on was looking at my association, the Canadian Association of General Surgeons idea that, you know, we may, we may see ourselves as diverse and, and welcoming, but I don’t think we’re as diverse as we think we are. And we have a lot of ways to go in terms of ensuring that a lot of groups are included this idea of diversity, even if you know, there’s a lot of Southeast Asians or Asians included. Does that mean just because we’re there, that we’re being diverse to other minority groups? And so that’s, that’s kind of my take on it. And my idea, and this is why I’ve been kind of proposed this idea of, of Global Diversity and make sure all groups are included in this diverse concept.

Chad Ball  10:46

Yeah, that’s very well said Shahz, you really been a champion to that nationally in the last few years. And you know, all of us can’t thank you enough. Morad… Dr. Hameed, if we come over to you, I’m curious how you frame and how you process the concept of racial diversity within surgery in particular, although I think we’ll get into it a little bit later. With your leadership position as the as the section head of general surgery on a big institution like UBC, how does that inform an impact? What how you think of it what you do?

Morad Hameed  11:19

Yeah, thanks, Chad. For me, growing up in, in Edmonton in the 70s and 80s, I was very conscious of race and racism. And I expected to encounter it in when I started my, my medical when I started medical school and surgical residency. But surprisingly, I, my personal experience, hasn’t has been very positive. I’ve never personally encountered racism, to my knowledge, and my colleagues have always been a diverse group with very positive interactions. And I guess this follows up on what I understood Shahz just said just now, which is that there is some apparent diversity in in the surgical workforce, but maybe it’s not uniform, and maybe there’s not, we still have a long way to go before we achieve true equity and diversity in the workforce. But at a high level and for me, personally, my experience has been good. And I’ve always felt welcomed by my mentors, and by my colleagues and by my patients. So, you know, I think that, that that lens of being aware of race also transcends to our patient experiences, and our research groups have done a lot of work on the social determinants of health and thinking about race and and Shahz, and Chad, you’ve been involved in many of those studies. And we see, you know, we know that this problem exists, because we see it in, in access to health care and in the outcomes of health care among our patients. So I guess, in summary, you know, I, my personal experience in in health care has been good, I know that we have a long way to go. I would love to tell you what approach we’re taking with the division of General Surgery at UBC, and from, from the perspective of our patients, our our studies have joined a great body of literature in the world that shows that there’s a tremendous disparity based on the social determinants of health that remain to be explored further.

Chad Ball  13:43

Julius, if we, if we come back to you, I realized this is a hard question and, and appreciate your thoughts. But, you know, in particular, you know, having been in the US for a while, as we mentioned, growing up in Canada, for a large part of your, your youth within medicine anyway, what are some of the potential struggles that you’ve had with regard to racial equity. I mean, my observation of you over over a very long period of time is that you handle everything with, you know, grace and elegance and humor, but, but I can’t imagine that you would have skated through all of these different environments that you’ve, you’ve been through without having some issues here and there along the way.

Julius Ebinu  14:21

I think a lot of how I have handled or dealt with, with, you know, sort of racial biases has been sort of from my upbringing. And I’ll just give a little background for those of you that don’t know. I I was in a boarding school at a young age in Swaziland and, and it was a boarding school that was set up with the premise of promoting international tourism as far as cultures go. You know, they’re called the United world colleges, which they’re there all over the world. They have satellite locations, and, and at the time I was there, it was the same time when Nelson Mandela was in prison. So Swaziland, basically for those who don’t know, is, is a landlocked country. And it’s right above South Africa and at the time, you know, whenever we would go to South Africa, you know, we would go to places where you would see signs that would say whites only, you know, colors, which are the mixed racism then, and then blacks, right. So. So, you know, the impact of that was tremendous, but not so much from the perspective of, of, you know, me feeling like, my race was inferior. But more so from the perspective of being at the school where we had various races that actually respected me as an individual, and looked beyond my skin color. So I think that early exposure, and an understanding that, you know, there are people that would, would have certain opinions as far as you know, who I am, you know. You know, and, and those specific opinions may not necessarily be universal to other people. And I think I learned at a young age. Having said that, um, you know, yes, I’ve lived, you know, growing up in Canada, and, as well as here, United States, and, and I will say, um, you know, as far as racism as far as racial bias, I think, for the most part, in Canada, it is prevalent, it’s subtle, right? It’s very subtle, and you sort of see it, as you sort of live your daily life. And, you know, just to give you a random example, you know, I’ve had many occasions where, you know, you’d go to a store, and for whatever reason, you know, you’ll notice someone following you around the store, right? And, you know, it’s not like you’re the only person in the store, but you’re sort of, you’re aware of those little sort of subtle subtleties where you feel like you’re being singled out, because of your race. You know, as far as the educational system goes, in Canada, you know, one of the norms for me going through the system was, was pretty much being, you know, one of the only black people within within my class, or within a given group, right? And it, you know, it, you know, within Canada, you sort of, you know, because it’s so diverse as a whole, the impact of that isn’t that isn’t as great. Um, you know, but but I think when you come across the United States, the impact of that becomes more, more relevant. And what I mean by that is, I think there’s systemic perceptions, biases, when it comes to race, here in the United States. And, and it’s deeply rooted within this within this country, you know, going back to slavery. And I think, part of the challenge here, United States has been changing that sort of systemic perception of different races and the stereotypes that are out there, where if you see a certain person of a certain race, there’s this automatic assumption that they’re either up to no good, or, you know, they can’t excel at, you know, a one thing or the other, right, so, yeah, I’ve had quite a few, I’ve had, you know, quite a few experiences with regard to racism. And my, my first encounter here, United States, when I went to when I was in Boston for, for my, my postdoc, you know, I took the opportunity to walk around, you know, Harvard and whatnot. And, and, you know, obviously dressed like everyone else, it wasn’t really anything unique, about about, about how I looked and. I remember this, I mean, distinctly, so I decided to go check out the labs, within the medical school, and, you know, there was always a security guard at the door. And so I walk in, and, and automatically, the security guard says to me, oh, you know, you must be here to come and fix our plumbing. Right? And, and, you know, I was a little taken aback by that by that statement. And, you know, immediately I was surprised, actually that at the, at the, at the, you know, that that statement. And I said to him, I said, You know, I said How did you guess? And he said, Well, there’s not a lot of people like your round here, right, as in within I work here in this facility. And I said, Wow, I said, fair enough. So I said, Actually, no, you know, and I had my, you know, my all my papers as far as registration, whatnot. And the fact that I was I was there as a student, and I said, No, actually, I’m actually here to take a look the lab because I’m one of the postdocs here and, you should see the look on his face. But I think for me, the most striking aspect of that was the immediate assumption, right? And that assumption was based on the fact that even within that building as a whole, there were not a lot of professionals or students or researchers that that looked like me. And that were there. And so, in his mind, you know, the immediate perception was, was that I was there to do some some jobs that he would typically see someone of my color doing. You know, and so that that was a, you know, a harsh and rude awakening to racism, and race relations here in United States. And I think, throughout the training, you do experience it with some patients. You know, at the end of the day, I think, you know, my goal is to, you know, as we’re all swored, you know, first do no harm, and I think, as long as we impart that, that, that understanding to our patients, then then, you know, you just sort of, you choose to ignore the other aspect of their perception of you as a as a, as a, as a, as a given race, as a Black physician. So, I will say, you know, the, the stereotype here in the United States is really strong, and it’s not so much even amongst those that may be primarily White, but even amongst Black people, because, you know, within a hospital setting, you know, you’ll see patients who happen to be Black as well. And they do comment on how how, you know, proud they are to see someone like me doing what I’m doing. Right. And that, to me is, you know, obviously, I’m very appreciative of the statements, but it but it’s also very disturbing, to hear that because, you know, you ask yourself, why is that such a tremendous feat for someone of color within this system? Right? Why is it that people are shocked or amazed to see someone, you know, like myself in a certain position. And so I think it just lends itself to some of the, the institutional racism that is here, the prejudices and, and the stereotypes that that seem to seem to be out there. And, you know, a lot of it is is also promoted by some of the social media as a whole. So, so yeah, I’ve had my encounters, you know, but by and large, I think I had a good foundation as a child and early exposure to knowing that there are good aspects of human beings. And there are bad aspects of few things. And I think, if you choose to view it as such, and to recognize that not everyone thinks along the same lines, I think, I think you’re, you’re one step ahead of everyone else.

Ameer Farooq  22:41

It is impossible to talk about this topic, as you mentioned, without talking about the role of social media and all of this. If you haven’t been living under a rock for the last two weeks, you know about what’s been going on with the Black Lives Matter protests, what would happen with George Floyd. And I think a big part of that has been social media and the role that that’s played both in the protests and in the response to that. And one of the things that I’ve often thought about and really struggled with is this whole idea of where do physicians fit in in terms of advocacy on social media. So I sent you guys all the link to a paper that was done by Langanfeld and others that actually looked at social media usage among surgeons and surgical residents. And what they were trying to do in this study is identify any unprofessional uses of social media. And they found quite a lot. But one of the interesting things that I noticed up front about that paper and other people’s like it is that they actually label as one of their criteria for being unprofessional as espousing a particular political opinion, or having very strong political leanings. And I’ve always really struggled with that, because I think on one hand, it is impossible for me as a physician, who cares about the health of my patients on a broad level, to not speak out on something that I think is, is dramatically and tangibly impacting their health. And I think racism in the US and in Canada, does play a huge role in affecting parts of our population and affecting the lives of black people in the United States. And then on the on the flip side, I really struggle with this idea of, you know, being a professional and I wonder how a patient would feel in terms of if they knew that I had a particularly strong political leaning. And so maybe I’ll turn to Dr. Hameed, as especially in your role in the UBC, where do you see physicians straddling  or navigating that role, as physicians who are impartial, but also care about their patients on social media.

Morad Hameed  25:08

Ameer, I was I was afraid that you were gonna ask me this question. As someone who’s maybe Tweeted like three times in his life, I, I’ve been slow to use social media. Interestingly, in the last few weeks, I have relied on Twitter to find all the articles that have been coming out about structural racism. And I’ve been following some of the tweets of the surgeons who are most active in this area to try to gauge the way people are processing everything. I think social media has tremendous use in that way to kind of democratize information and to, I guess, in some ways, amplify injustices so that they can, they can be seen by everybody. And so in that sense, I’ve actually coincident with COVID-19. And with with this, with these, George Floyd related protests, I’ve relied more on social media than than I ever had before. It’s been useful to me, just just to follow these, these movements. I also noticed that in the traditional media, which is increasingly polarized, that small incidents can be, can also be amplified sometimes just to just to increase traffic. And so I think it’s important to, to bring a lot of objectivity to what we’re seeing in both in social media and conventional media, because I think the line between those two things is, is getting a little bit blurry. But, you know, I think if we navigate this in a sober way, I think we can start to get a lot of information. And I think that emerging social movements have a lot more power than they did before, which I think is really good news for all of us who are working in this area.

Ameer Farooq  27:03

Dr. Karmali, we will ask you, do you think it’s unprofessional? And I don’t mean to put you on the spot, but I am I it’s something that I struggle with. And as someone who uses Twitter a lot, do you think it’s unprofessional for, let’s say a surgeon or a surgical resident to overtly come out and support a particular political leaning?


Shahzeer Karmali  27:25

Well, I guess depends on you know, where how you do it, and where you do it. So I know, like on, I’m pretty active on social media. So I know, on Instagram and Facebook, there’s their, you know, there’s a group called White Coats for Black Lives Matter. And it’s, it’s a, it’s a strong group. So it’s primarily doctors who stand up and you know are doing their best to convey that the Black Lives Matter movement, which is very important right now. So, again, that’s that’s an important political platform, I guess it depends on your take. You know, I have friends who, who are on social media, and they post on their own personal accounts, and some are very, very vocal, but you know, I guess it depends on where you’re posting and how you’re posting. If you’re posting as, as a physician representing a certain group, I think you have to be cognizant of what you’re posting. Whereas if you’re an individual, I mean, you have the right to free speech. I mean, as long as you’re not doing it, within your workplace or doing it in, you know, in a capacity where you may be impacting other people or impacting, you know, at least for in the health care setting your patients, then I think you’re pretty free to speak as you wish, realizing that you have to be careful work with what you say, because it can impact you both personally, as well as professionally. So in the end, it comes to that dichotomy of, you know, free speech versus, you know, versus, you know, impacting what your career is, right. So, I think it’s, it’s a happy balance, and we have to all decide what’s more important in terms of that balance, right. And if you feel that what you need to say is, you know, regardless of what you say, is what you want to convey, then you have to make that decision for yourself. Right.

Ameer Farooq  29:12

Dr. Ebinu, I think you’re perhaps more directly affected by what’s going on in the US than, than any of us. What’s your take on the huge you know, discussion that’s been going on on Twitter, and I’ll put the link for this in the show notes as well. One of the things that that I found particularly powerful was that the hashtag black and the ivory, where people talked about their experiences being black, very, very similar to what you described, while in academia or in medicine, etc. What are your thoughts on on this very challenging topic, particularly, I think if you’re a trainee?

Julius Ebinu  29:54

Yeah, so I guess the question pertains to being Black in a predominantly non-Black environment. As far as the education system goes, I think, you know, I think that the challenges is one recognizing that and not having that affect how you perceive yourself. What do I mean by that? Well, you know, within this society here, United States, the overall perception when it comes to minorities and people of color is, you know, is the fact it is a suggestion that they may not be as, as intellectual as other others, right? And so you have yourself in this scenario, where you’re the only person of a given color in an environment that already has his, you know, stereotype of your abilities and capabilities. And so, so I think for those that that don’t have a solid, you know, ground or foundation as far as who they are, as an individual, and what they’re about and what they represent, as far as the capabilities, that can be a struggle, because because there will be a lot of challenges throughout the training program. And, you know, in as much as, you know, we talk about free speech, and that free speech, hopefully, you know, would be supportive of, of a more acceptable environment, there are those that don’t have that same mindset. And so, navigating that, that is challenging. And I’ll give an example. And this is actually just recently had a, you know, one, one trainee coming from a different transfer actually two years ago, from a different institution where they went through a lot of hardships, you know, as, in as much as not been given the opportunity to operate and just being made to feel insecure about their capabilities. And, and so it got to a point where they, they left the program, and, you know, we accepted them. And, and there was a little hesitation upfront, because, you know, someone’s leaving another program and wonder what, what actually happened. But the reality was, and I had a conversation with before I even started, and I said, you know, you know, part of the challenges is, is one proving to yourself, you know, what you’re capable, but the other is, you know, proving to other people. And I said, you know, when it comes to training, you know, the perception of who you are, as an individual or trainee should not be dictated by those that criticize you, because what you feel are racial biases. In other words, know what you’re capable of, work hard, and the rest will follow suit. And he did an amazing job. Why, because he was given a lot more opportunity, a lot more independence, and a lot of had to do with, you know, giving him the confidence within himself surgically. And he forged I mean, he just, he’s a bright kid, but he forged, you know, and graduated with with great recommendations and so forth. So, so I think, within a system, one has to acknowledge that, yes, there are biases, and I think more it’s important to work on on, on yourself, as that unique race, realizing that, you know, whatever stereotype is out there, your goal is not to prove anyone wrong, but to better yourself, both as an individual and as a physician. Because, you know, and, you know, undoubtedly you will encounter scenarios where, where you’re treated a certain way because of that, and this is not just the United States, but it’s also in Canada. And the hardest thing is day after day after day dealing with that, that whole concept of you know, maybe I am not as good as, as I think I am. Maybe I’m you know, inferior to those around me. Which which can really play a take its toll on a on anyone going through a program, right. It’s stressful not being a trainee, but throw that into it, and it becomes that much more stressful.

Chad Ball  34:03

That’s that’s very well said, Julius, there’s no doubt. Morad, if I was to ask you, how do microaggressions play into this may be in the Canadian context? Because you and I’ve discussed before, and is really Julius and Shahz both pointed out here. I would, I would argue that again, as you know, being very cautious as the as the middle-aged White male in this conversation that overt, almost aggressive racism, at least in my experience and observation is much less common in Canada, but probably the way that we, we we end up manifesting that is through microaggressions. What what’s your thought on that?

Morad Hameed  34:46

Yeah, I think microaggressions is a bit of a new idea for me and I I didn’t it took me a while to understand how they might have affected me. Maybe I’ll tell you a story. I was a visiting professor at a university, not in Canada or the US and I was waiting to be introduced to the head of the Department of Surgery and I was in this oak paneled office waiting for him to come out. And the paint the pictures on the world, the portraits were of all the previous chairs of surgical departments. And they were all old, white men. And so I looked with interest and, you know, try to imagine how their lives were in each decade that they were chairs. But I was a little bit nervous, and I didn’t quite feel at ease. And when the chair came out, finally to meet me, he was about maybe five, six, and an Indian guy, then he was like, super cheerful, and, you know, he said, Well, you know, come on, and, you know, how are you doing? And I realized that a little bit of sense of relief at that moment that I thought that sense that you may not belong in a room, I guess, is what, what how microaggressions make you feel. And, you know, those microaggressions may not even be intended. But, you know, I’ve been very influenced by Daniel Coyle’s book, “The Culture Code” about how to build cultures that, that promote imagination, and risk and success. And one of the key elements of a successful culture according to Daniel Coyle, is, is belonging like to, to address that fundamental human need to belong. And even if there’s subtle cues that you don’t belong, I think it detracts from, from our culture, and, and it and all of us bear the cost of that, of that limitation of, of culture. We all need everybody we need input from, from all diverse perspectives to have the best organizations that we can. And I think that those microaggressions whether intended or not, can totally derail entire cultures.

Chad Ball  37:05

I couldn’t agree more, Morad. You know, in particular Coyle’s book teaches us so much about so many things. But, you know, I always sort of took that, that that book as as exactly what you said. But the other half is creating and they go hand in hand, but the other half is creating a safe environment where you feel like you say welcomed, and that you’re able to share and be honest with those around you. And and certainly in in health care with additional hierarchical model, there’s been examples where that’s not been the case. And and when you look at some of these experiences, whether it’s James Kerr’s “Legacy” book about the All Blacks, it’s probably the single greatest and most sustainable team concept, being their rugby team in New Zealand. Really, these these same sort of concepts of eliminating microaggressions providing a safe environment where, you know, honesty and openness and conversation can happen really equate to long-term success and, and do to be honest, have to be revisited over time as well. Because even with the best intentions, these things get stagnant.

Morad Hameed  38:13

And there’s something new about which is Scott Page economist who talks about diversity and complexity. And I was struck by that example. He talks about diversity in organizations. And he says that a lot of us think that having a diverse organization is a is a moral imperative. Like it’s nice to have in a progressive society. But it but he argues that it’s not just a nice to have. It’s like it here and he goes on to do this mathematical derivation that actually tackles complex problems, than more homogeneous team. And I think using like, if you take the top 10 students from a 200 class, business class 200 student business class. You can pick those top 10 by any criteria that you want. And then you take for an example you take 10 people from that same class. If they are managed well to that will always almost always outperform Africa, simply because they bring more perspectives and they work two problems faster. So it’s not just a nice to have its diversity is is essential to have.

Chad Ball  39:29

Shahz, maybe the Annals of Surgery recently published a statement that was formal and it prioritized rapid peer review, publishing and then and then studying equity and diversity and in particular, within the surgical workforce and their their desire to have those papers submitted and we tried to do the same thing in the Canadian Journal of Surgery in October with an editorial last year. And when we looked at it, you know, the Canadian Journal Surgery accepts about 50% of you equity and diversity related papers, whether that’s gender or racial. In particular, I’m curious as somebody who publishes a fair bit and lives in that academic world with a lot of us, what’s your view on that? And do you think that the traditional peer reviewed journal process and outlook in that way it would be helpful? Or is the social media world much more important?

Shahzeer Karmali  40:24

So you know, the craziest thing Chad is like, the the crazy when you think about it right now, and 2020, we’re still talking about stuff like this. Like, I mean, it was just amazing looking at the news, looking at NASCAR, like NASCAR, just took away the Confederate flag in NASCAR, like, what what is going on? Like I don’t, it’s just, it’s just fascinating and intriguing that we’re talking in 2020 there in, you know, especially the US are taking down, you know, monuments of slave owners, which they shouldn’t even been up. And so it’s, it’s always a question of like, what, what are we doing now? Like, does it it makes no sense. Right. And so, I guess tackling about a question of, you know, diversity and publications on I guess you can, you can publish all you want on it, but I think in the end, you know, you publish on it, and then you know, how it is a new cycle changes is something else comes about. I think the better idea is trying to figure out what what we can do to, you know, improve things. So, rather than that is I mean, I think the idea is encouraging publications from diverse groups of individuals, right. So, you know, publish on whatever concept you you want to, we want to tackle on. And I think we can we know, we know, we know that we know, there’s lack of diversity, we know that there’s microaggression. I think that’s known I think the the next step is, you know, what, what do we do about it. That’s, that’s why, you know, this Black Lives Matter movement is very strong, and I hope it doesn’t stop. I mean, it, you know, it comes about and it goes away. And that’s why I think, you know, all groups need to need to link up and work with Black Lives Matter and, and really support this movement, because I think this movement will move forward, even if, you know, I’m not African-American by by descent, but I think supporting this movement supports all of us, right? It’s right now we realize that, you know, our African-American brothers are being marginalized. So as a group, we need to stand up for them. And so I think that’s, that’s a take. So I guess getting back to your question, you know, is should there be a push for racial I, you know, papers talk about, you know, diversity in, in racial, you know, racial imbalance. Sure, there sure there should be, but we know this is going on. I think the push should be figuring out how we improve things. But what are we doing to improve things rather than saying, well, it exists thanks for thanks for publishing my paper on it.

Chad Ball  42:47

Certainly one of my concerns, you know, as a, again, a middle-aged Caucasian male surrounds the the legacy or the or the feature of this movement. And you said it so eloquently. What I you know, I personally, I’m really excited about it. Like this conversation has to happen, it has to continue like you like you comment. But Julius, I’m, I’m a little bit concerned about the the political or the political politicization of this in the US. And it seems like, the purity of the message in only two to three weeks, is now being diluted into potentially many other things that certain groups left or right, are using, maybe for other less altruistic purposes is is that an over or an over call on my part? Or is that something you see is going on down there?

Julius Ebinu  43:42

I I tend to agree with you actually, I think, um, I think that is a case. You know, it’s interesting how, you know, Shahz’s point out, you know, there’s been a lot of incidents where, you know, the whole Black Lives Matter movement has come about but, but for some reason, this time, things are different. And I think in the past, more often than not, the reason why things die down or so that driver passion sort of fades away is because it becomes associated with some other aspect of either politics, or what have you, that really deletes out the essence of what what that means, right? And, and it’s unfortunate, because I think here in United States, you know, this whole bipartisanship, you know, as much as politics, and now it’s sort of invading as a word, you know, the health care system, religion, other aspects of our daily life, is, is is, is quite disturbing. And I think, you know, until we view until we view things in a sort of a neutral zone, without bringing and masking the essence of what we’re actually trying to deal with, we’re always going to have that issue, right? You know, I think Canadians are, Canada is a bit more level headed as far as when it comes to politics and their understanding of some of these social issues. And so by and large, I think Canadians fully do understand, you know, what, what, what, what that means, as far as Black Lives Matter, and, you know, and diversity as a whole. And I, you know, I, I hear it here a lot, where people, for some reason feel that, you know, it’s diminishing the other races, which it’s not, it’s just acknowledging a particular race as being as relevant as the others. Right? So so the politics here is is pretty is pretty intense. And it does do dilute the message, unfortunately, it it can cause a certain debate. But I think this times a little different and we will see how how it pans out, especially, you know, with with the upcoming elections in, in November so.

Chad Ball  46:00

Yeah I’m sure there’ll be dramatic, I have no doubt of that. Morad, you know, as we get closer to the end of the podcast here, and again, thank you to all of you folks for, for helping us better understand this as listeners. Morad I’m curious, from the leadership point of view, you know, you run a very big program in UBC with a lot of other talented people. I’m curious how you see the concept of structural racism, maybe locally, or certainly nationally, and I know what your thoughts are on some of the ways that we can approve, maybe collectively as well, specifically going forward.

Morad Hameed  46:38

And, you know, I’m still learning a lot about this, and trying to listen, to figure out the right strategy to move forward. I’ve certainly learned tons from all of you tonight and learning from my, from my colleagues and waiting to hear back from our residents and medical students about the right course to chart. And particularly have been influenced by one of my colleagues, Hamish Hwang, who’s a general surgeon in Vernon. And he, he’s really felt strongly that whatever we do, and I think all these wider social movements are reminding us and empowering us to think more deeply about this and to scrutinize everything that we do. To look for evidence of structural racism, racism, that’s embed embedded in our clinical decision-making and in our resource allocation. And really, to take a longitudinal approach like this is not this is not a quick response, or this is this has to be a long term sustained response. And I think any response has to be nuanced. It has to think about the different types of racism and bias that exists in our system, whether it’s by race, or culture, or language and, and how patients might be marginalized because of these things. And then to design culture or race or, or socioeconomic status specific approaches to diversity and exclusion. So I think that this, this has to be the standard operation of surgical divisions and departments from now on is to always have an eye on on diversity and inclusion and culture.

Chad Ball  48:28

Shahz, what do you think we can do in within Canada to continue going in the right direction here and continue to improve things?

Shahzeer Karmali  48:35

Well, you know, I think the main thing Chad is as individual people, we have to speak up about racism, and there was just an article published, I think, in BC, where they noticed that, you know, there’s an emergency department in BC, they’re actually taking bets on indigenous people coming into the ER and betting, you know, having bets on who can guess their blood alcohol level. And, you know, it’s things like that, that really needs to be raised. And as individuals, whether you’re Black, brown, yellow, purple, pink, whatever you are, I think if you see, you know, whether it’s, you know, overt racism like that, or even indirect racism, or even, you know, microaggression, I think it’s important to speak up, and, you know, mention, you know, this is not the right way to do it, or, you know, raise it to higher levels. That’s the only way we’d be able to fix things by working together, right? If you just rely on one group to do it, I don’t think it’ll work but as a community as a population, you know, we have to all agree that, you know, it’s not the right thing to do. And that’s why I’ll go back to Black Lives Matter. This is where everybody supports the same movement to say that you know what, it’s not right. We all support it, regardless of who we are. And I think that’s, that might be the only way we can kind of fix the inherent promise lasted till 2020 already, right?

Chad Ball  49:59

Yeah, I think you’re right. I mean, it’s, it feels like maybe we’re finally in a time where or intentional insensitivity or maybe even blind ignorance is finally on showcase. And, and that showcase is going to allow all of us particularly those affected to point out some of these issues and call folks out on it when, you know, hopefully in a productive, constructive way, but moving forward. Julius, we’d love to give the last word to you and get your thoughts on how to move forward and what we can do both in Canada and beyond.

Julius Ebinu  50:33

Yeah, so I think I think first and foremost, you know, what first thing to do is understand and appreciate, and acknowledge that diversity is important. And that diversity plays a huge role in how we function as a health care workforce, how we function in terms of the trainees that we have, and developing our trainees and, and then also, in terms of addressing some of the health care disparities. You know, Shahz’s example of that emergency department really lends itself to the importance of diversity, why, because there’s an element of sensitivity to various cultures, that as a physician, we should be able to recognize, right? And, and for those of us that may have some preconceived perception of minority patients, you know, we need to have that sensitivity to recognize that this may play a role in our ability to treat, you know, minority patients. And it may also contribute to to some disparities in health care among racial and ethnic minorities, you know. Having a diverse workforce would, would that least help curb some of those incidents. And as much as educating your peers, as to the importance of being sensitive to various cultures. But I think on a positive note, you know, when it comes to diversity, I also think of research and you know, more recently, there was a successful so far, you know, experiment using a genetic modification of the patient using CRISPR, you know, the CRISPR gene for for sickle cell. And it’s it highlights the importance of not only educating people about diversity, but also implementing research that addresses diseases that may be unique to certain populations. So so that as a whole emphasizes the importance around of diversity, both in terms of the research that we do and the education that we impart. You know, I think it’s unfortunate that it took that incident of, you know, this police officer and the murder of a you know, one civilian who happen to be Black, but but I think as a as a nation, both here in the United States and in Canada, it really has increased and heightened our sensitivity to some of the racial biases that may be inherent, either in the educational system, or otherwise. And just as individuals, asking ourselves important questions as far as race, race relations and how it might impact our day to day lives, and more so how we administer health care is important. So so you know, I think the future looks promising. I do think there’s a long way that we have to go. But at the end of day, I think I think we’re going in the right direction.

Ameer Farooq  53:34

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.