Paul Wilkinson- Series 2 - Racism

[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group, or CUMEG for short. This is a podcast from the University of Cambridge Clinical School, focusing on medical education. We'll be touching on a range of topics that medical educators are dealing with. I'm your host Cheryl France, Head of CUMEG.

Today, I would like to introduce Professor Paul Wilkinson, Clinical Dean at the University of Cambridge Clinical School and Honorary Consultant of Child and Adolescent Psychiatry. Paul has been the clinical dean since 2021, and today is going to talk about his role as clinical dean and the important topic of reducing racism in medical education.

Welcome, Professor Paul Wilkinson.

[00:00:47] Paul: Hello, Cheryl.

[00:00:48] Cheryl: Great to have you with us today. So thank you for taking time out to speak with us.

Can you tell us more about yourself and your current role as the Clinical Dean at the University of Cambridge Clinical School?

[00:01:00] Paul: Yes, certainly. So I've been in Cambridge for a long time. I was a medical student here and did my training. I trained as an academic psychiatrist, so as well as learning the clinical side of things. I've been doing research in adolescent depression and self-harm since about 2000. I think as time's gone on, I found that the education side was a lot more interesting than the research side, and I found that I was probably better at it. So I gradually took on more and more leadership roles in education. I led the psychiatry course at Cambridge for about 11 years and led medical education research in year five, and then was appointed to be Clinical Dean at the beginning of 2021.

[00:01:42] Cheryl: Fantastic. Thank you. Wow. So your other role is fascinating and something that actually we could come back and talk about quite a bit because particularly with the pandemic, your previous research I'm sure had a lot of implications and need to study and understand more.

 But today we do want to understand more about your role as the Clinical Dean, which is quite a diverse role.

[00:02:08] Paul: Yes.

[00:02:08] Cheryl: And I'm sure quite challenging times.

[00:02:12] Paul: Yes.

[00:02:13] Cheryl: So one of the areas that you and your team have been working to improve is racism in medical education. So my understanding is this is an initiative that actually came from the students themselves.

Could you tell us more about why that was instigated and what's been happening?

[00:02:34] Paul: Absolutely. So just over two years ago after the murder of George Floyd, a lot of people got very energized in thinking about racism. And that included the medical students here at Cambridge. So a group of well over a thousand of them sent an open letter to the clinical school leadership complaining about the racism in medical curricula not just in Cambridge, but throughout the world, and said to us that we really needed to improve what we were doing to address this.

It's important to hear when I say we, that I wasn't the clinical dean then it was my predecessor who initially led this work, although I was part of it from early on. So we agreed that we'd meet with the students. So a large group of the teaching faculty and a group of students had a really, really productive meeting in talking about this. And we were really impressed as faculty with the way that the students had handled this because, they had, rather than come to us with a list of vague demands, they came to us with evidence. I guess hopefully that shows we do teach our students how to look at evidence and use it, but they came to us with a lot of evidence about the racism that's in the curricula and the problems it was causing, and a list of very sensible changes they recommended. And so we spoke about these. We also added some ideas ourself, and we came up with a list of three areas we thought it was really important for us to work on. We've now expanded that to four.

Initially it was three, and the three main areas were firstly curriculum and assessment, which I guess is the biggest area. So that referred to what we actually teach the medical students and how we go about teaching it and how we do assessments. There's a lot of bits to that and I can come back to that.

The second area was staff development. The recognition that our staff didn't understand enough about racism. Therefore, it's very hard for staff to teach students properly if we don't understand things.

And then the third area was about student safety, about the fact that actually a lot of students had faced faces in themselves and didn't feel that they were able to get help for it, didn't feel that they were able to report it properly. So we set up a strand, which we called Report and Support, where students have clear access to reporting systems. So action can be taken in the event of racism. But this is paired with the students being supported when doing it because it's both traumatic to experience racism, but also traumatic to go through reporting it, especially if it's against somebody senior.

[00:04:56] Cheryl: That's really fantastic that they took the driving seat and such specific changes.

 Quite concerning that last one. It is a good point and the fact that people do need to report it, but it's challenging to report things. So I think that's really interesting. I mean, could you go into a bit more detail for each of those. And you said there's a fourth one as well. Could you tell us some of what's happened and some the details?

[00:05:26] Paul: Actually, the fourth one is just splitting one of them. The curriculum and assessment, we realized was so big, it was very difficult for one group to actually do both. So there's now a curriculum group and an assessment group.

[00:05:36] Cheryl: Okay.

[00:05:36] Paul: And actually what's happened since then is, so I should have said this, we've set up working groups for all those four areas which have taken the work forward. And we have a steering group which meets regularly, where the group's feedback and the steering group and each of the subgroups are all co-chaired by a student and a member of faculty to recognize just what a great job the students are doing. And they know more than we do in lots of areas so it makes sense for them to co-chair this work.

[00:06:03] Cheryl: That's brilliant. It's good to ensure that they are at the heart of it and making accountable that the changes that we're making are appropriate and are fulfilling the needs and the concerns that they had at the beginning. So that's great to know that they are in the driving seat.

So, can you tell us some of the details of, you don't have to go into depth of detail, but you know, some of the specific changes that may have occurred in each of those areas?

[00:06:32] Paul: Yes, certainly. So the curriculum group is the largest area. So the first part of that is actually teaching students about racism, what it is, what causes it, what problems it causes, and that comes at several parts of the course. So it's included in the preclinical course, in the social and ethical context of health course, and it's included in the clinical part of the course under the improving health strand, so students have a better understanding.

The next area we've looked at is making sure that all of the different courses we teach consider ethnicity and racism as part of that. And that's something I had a big role in psychiatry, because I was psychiatry lead at the time. So we went through our course and we had to think about how we need to cover this. This was, I got a lot of support here from both faculty and students of a really diverse set of ethnic groups who had knowledge in lots of different areas. So we were very much able to improve what we taught in psychiatry so that students do now understand how ethnicity is important in mental illness in many ways, in terms of how students do assessments and how they may need to be different. They may need to cover other areas so that they're complete in thinking about how people may access treatment differently how they may have different views on treatment. And the way we did this is we produced a manual for students, which explains this in lots of detail. Kind of a mini textbook, but also in our small group tutorials that we do, we change some of the cases. So our tutorial on schizophrenia, we changed so that this was a black man with schizophrenia and how that may have and how as doctors, we need to consider the ethnicity in doing the assessment and in the treatment. And our tutorial on depression we changed to a Bangladeshi middle-aged woman.

Now, big danger of doing this, it's very easy when you write these, especially if you're a white man, to be very stereotyped and actually perpetuate racist myths rather than actually help students. We therefore made sure we had students from those ethnic groups to help us to write those tutorials so that they had a really good sense of understanding of what it's like in their own communities, but to ensure that this was written in a way that was helpful and didn't actually make problems worse.

[00:08:52] Cheryl: And I think that's really important. It's about engaging the communities that are involved, but also for each topic not to just say “oh, it only happens in ethnic groups.” Because I think that's the other thing. You could almost go too far and say, oh, well these issues only happen. There are some illnesses, you know, when you think about diseases that are more prevalent in some populations and that's important to highlight.

[00:09:16] Paul: Absolutely.

[00:09:16] Cheryl: But equally we don't want to put everything on a different range of ethnic groups, so that's I'm sure interesting and challenging in its own rights.

[00:09:26] Paul: Absolutely. And actually that's led us to do something else in our, which we realized over time is that, rather than make our assessments different for people of different ethnic groups, actually what we should be doing is high quality assessments in everybody because some of these issues that are seen as being more prevalent in some ethnic groups can happen to anybody.

So actually we need to make all of our assessments of all of our patients, more comprehensive rather than do a different one for each ethnic group.

[00:09:52] Cheryl: Yes. And I think that's quite interesting in itself to, you know, kind of pull us all out of that bias as it could be called as well.

[00:10:01] Paul: Absolutely.

[00:10:02] Cheryl: And only looking in certain groups, so that's quite good.

[00:10:06] Paul: Absolutely. And so that's what we did in psychiatry, but we've done this across lots of different specialties and what we are doing is that this group is working with specialty and theme leads to help them to look at their teaching. And how to improve it to make it more ethnically sensitive.

[00:10:19] Cheryl: Okay because that, and I think that was one of the things that you highlighted, was the fact that its faculty needed some of this training as well.

[00:10:25] Paul: Absolutely.

[00:10:26] Cheryl: And so, how have you been working with the faculty to change that?

[00:10:31] Paul: I guess in multiple ways.

I mean, partly it's by having people from the group who know a lot about these things, working with specialty leads who don't know as much to help them to look at things afresh. The other thing we're doing kind of in the staff development area is a big focus of that has been active bystander training. That racism happens. And I think the events of the last couple of years have really made people like me realize much more how it does happen. Because I don't experience it, so I don't know what it's like. And actually students tell us more about what does go on. And actually, what's important is that we as doctors know what to do when we see it.

So if we were to see a patient make a racist comment in the room about a medical student who's in the room, what do we do? What do we say? How do we approach it? Because it's complicated, because it's actually easier if it's a colleague because we can tell the colleague, no, you can't do that. But with a patient, yes, we should be saying that, but also we are there as their doctor. So how do we actually have that conversation in a way that maintains the therapeutic relationship, but also keeps the students safe? And it's not something that's an easy 30 second answer. So we're rolling out a program of all of our senior, all of our teaching leads to help them in active bystander training.

[00:11:52] Cheryl: Yeah. That is quite complex.

[00:11:54] Paul: It is.

[00:11:55] Cheryl: But, as you say, it needs addressing. How do you address it? And each circumstance may be different.

[00:12:01] Paul: I think that's the thing, each circumstance is different and I think it's, I can't really give you a ten second, 30 second answer of how to do it, but I think it's about making sure that it is properly addressed so the patient knows it, but is done in a way that isn't confrontational.

[00:12:20] Cheryl: Yes. And that's really important because it's that confrontational aspect that could feel aggressive for the patient. For everybody in the room actually. So it's how to handle that regardless; I think it's an uncomfortable situation, but something that needs addressing. So it's important that, that is now being taught and considered, and thinking about different scenarios to help both the doctors who may be witnessing it and or experiencing it as well as the students.

And I think it's important probably for the students moving forward in the future to recognize that they don't have to sit by and listen to somebody, treat them unfairly, because that's not appropriate.

[00:13:05] Paul: And a lot of this is actually about educating patients. One of the things I've learned a lot about in the last couple of years is microaggressions. Yes. Some people sometimes make really extreme racist comments that are obviously totally wrong, but what's far more common is the small comments that people don't realize are offensive.

But if you experience them three or four times a day, five days a week, really get to you. And actually that's probably a bigger problem and our students have given with the open letter, they gave us a whole load of examples of the kind of things they've been hearing from patients. And actually you can see why it would be offensive and patients don't realize it.

So it's about, actually, if we educate the patients, they're often actually apologetic, because they didn't mean to be offensive. But hopefully it means that those patients then go away and stop asking people where they're from or commenting that they speak good English. And of course they speak good English, they're brought up in London.

[00:14:01] Cheryl: So can you tell me a bit more about where students might experience this racism and what's being done about it?

[00:14:09] Paul: Yes. So there was this, the students themselves did a survey about this, which came with the open letter they sent, but also there's a separate survey done at the university about this, and what it showed is like in the rest of society, our students are facing racism. They're facing this sometimes from university staff, medical students are facing it on placements from NHS staff. They're getting it from patients themselves, not just staff. And they're also getting it went out and about in Cambridge, in shops, on the streets.

And this is a big problem for them because it builds up and it affects their mental health, affects their wellbeing. It makes it harder for them to manage their studying, and it's something that we need to do what we can do to reduce because we need to protect our students as a university.

[00:14:55] Cheryl: Absolutely. And you know, as you've talked about this, I've had the chills thinking, why is this happening in today's society? Why is this an issue? It's heart-breaking.

But I also think it's really important that we are talking about this so that if we as individuals are ever being, you know, saying a comment to somebody that could be offensive, like, where are you from? You might be thinking you're being friendly, but actually that's not friendly. That could be seen as aggressive. So it's about thinking about our everyday comments, from everybody. But it is upsetting that we are having to do this, but I'm so pleased that we are doing something.

[00:15:36] Paul: Absolutely. And I think it, this isn't a university specific problem. It happens at the university because the university's in the UK and this country has a problem with this.

And as a university we are, I do believe senior leadership are very committed to reducing it, but it's still there and we have to do something about it. And I think it's progress that there is that acknowledgement.

[00:15:57] Cheryl: Yes, absolutely. Absolutely. And I think it's fantastic that the students felt empowered to do their own research, to write the letter and to ensure that something will be done.

So, and that they're at the front seat of all the work that's happening. So I think that is really empowering and fabulous to hear that the university has taken it so seriously. So from that perspective, there is something positive coming out of that.

[00:16:26] Paul: Absolutely.

[00:16:28] Cheryl: so there's also been another strand of work, if I'm correct in understanding something called Health for All.

[00:16:34] Paul: Yes.

[00:16:35] Cheryl: So my understanding of that piece of work is that it allows students to take forward important initiatives. So the tagline from my understanding is it's the collective desire to create a system of medical education, medicine, and a wider society that is fair to everyone.

So, I understand the students have come up with a range of topics on that piece of work that otherwise may not be addressed through medical education.

Is this something that we perhaps need to take further?

[00:17:10] Paul: Yes. I think this is something they did come from the students with a group they had called Doctors for All and as faculty, we've now taken this forward in our teaching and we did a lot of early focus on racism because it is so important.

But it's not the only important area. There's other sources of inequality and I think what's important for us as a medical school, and I say my leadership team agree with me on this, is that we need to prepare our students to be doctors who are going to be safe, competent, effective, and sensitive doctors for everyone they treat, not just the people who look like me and sound like me. Or sound, look and sound like them. And so, yes, they need to be able to manage patients of all ethnic groups, but also they need to be sensitive to patients from the LGBTQ plus community. They need to be sensitive and they need to treat women with the same respect as they do men. They need to consider patients with disabilities hidden and non-hidden.

 And these are all things that are listed in the Equalities Act, but actually they're not the only areas of inequality. There's wealth inequality, which of course feeds into health and that we have the inverse care law, which shows in societies throughout the world, is that the people who are the poorest, who most need help actually get the lowest access to health.

So how do we address that? How do we address marginalized groups in societies? People like prisoners, sex workers, travellers who have much less access to health than people more in the mainstream of society. So we need to look at addressing everything and rather like the racism work, the Health for All group are working with people who lead bits of the curriculum and helping them to think about this in their work so that in each specialty and theme we are covering all of these important groups.

[00:19:08] Cheryl: Yeah, I think that's really important to highlight that. And I know I've looked at some of the topics that have come out and I've thought that's really interesting, you know, and it gives you that opportunity to look a little bit more in depth. And so I have a background in public health, so health inequalities to me is really important.

And as you said, it's something that people don't necessarily consider. But also I remember looking at something about women's health and very marginalized groups within women's health. And currently, or recently there was a document published in the UK about specific women's health and issues.

So I think that's really important that we do consider all different assets of society that have health concerns and how we look at that is really, really important.

[00:19:58] Paul: And I think an important thing here is the concept of intersectionality, is that many people face discrimination and disadvantage on multiple grounds.

In fact, I was reading this morning about a really good bit of work one of our students is doing to address period poverty, which is something that as a man with a good income, I might not think very much about. But actually a lot of our students who menstruate can't afford period products and obviously outside the university, there's a lot of women throughout the country who can't afford period products.

So this group is helping to address that and has actually done some great work in making sure period products were available for free in all the colleges.

[00:20:37] Cheryl: Which is fantastic. And you're right, that's something that's come out in recent years.

[00:20:40] Paul: Yes.

[00:20:40] Cheryl: And I just think it's wonderful that those sorts of initiatives are coming out and it's also an embarrassing topic for many women to

[00:20:48] Paul: Absolutely.

[00:20:49] Cheryl: You know, maybe not even want to go purchase them if they could afford them. So having something available for free, particularly for lower income

[00:20:58] Paul: Absolutely.

[00:20:59] Cheryl: Is wonderful initiative that's going on.

[00:21:02] Paul: Yeah. It's really important that all our doctors are aware of this issue with period poverty because it's something that affects so many people in this country, and our doctors need to understand that rather than just learn the biology periods.

[00:21:15] Cheryl: You're right. That's really important aspect of it and I think it's really been useful listening to a lot of these podcasts that I've completed so far and it isn't just about the science of medicine. It's about understanding the person as a whole. And so I think it's fantastic that you've brought that out again to show that we are teaching more than just this is the science you need.

[00:21:39] Paul: Yeah.

[00:21:39] Cheryl: So that's really important.

If you don't mind, I want to go back to thinking about racism specifically. So, you are a consultant psychiatrist by training. Are you able to talk about the psychological impact of racism?

[00:21:57] Paul: Yeah, certainly. I mean, in my research I'm a psychiatric epidemiologist and a big bit of that is understanding how risk factors work together to lead to illness. And most mental illnesses are multifactorial in the fact that multiple things add up a mixture of biological things such as genes and physical illness, psychological factors, so the way we process and think about things, and social factors, what happens in our environment and most mental illnesses are due to a of those things coming together and between they increase somebody's risks and they get ill.

Racism is obviously a really unpleasant thing for people to go through. Not surprisingly, racism increases the risks of mental illness. And there's been lots of very interesting research on racism with schizophrenia, which is a really severe mental illness, affects about 0.5% of the population, causes problems in people have abnormal false thoughts. They get to hallucinations, they find it hard to motivate themselves. They have a bit of cognitive decline. It's a really, really important illness that can make people very ill. And evidence has shown that actually rates of schizophrenia are much higher in black people living in America or Britain than white people living in the same country. Now people might think, oh, that's all genetic, because a lot of people see schizophrenia as a mainly biological and genetic condition.

However, it's not about genetics. Because actually black people living in Africa have the same rate of schizophrenia as white people living in Britain and America. There has nothing to do with genes. And in fact, further to that, there was studies back in way back in the last century showing that Norwegian immigrants in America had much higher rates of schizophrenia than white Americans, and also Norwegians living in Norway.

So this is about many things, but actually migrants do face racism is a big problem. And certainly studies looking at black people in America in particular show there's a very complex interplay of factors that probably lead to the increased risk.

So firstly, there's direct racism that black people face in America, whether it's from the police, whether it's from people they come across in school or in the workplace, that is traumatic. That's a risk factor, especially when it happens again and again and again. Also such racism often leads to fear. If you fear, if you have a feeling of fear when you see a policeman, that's probably not great for developing your mental health.

So part of its direct racism. Part of it may well be generational trauma by the fact that you know, as a black community, you face racism over the years. It's also about some of the indirect effects, indirect effects of racism, poverty. It leads to people living in more deprived neighbourhoods. They have less access to healthcare. In fact, pregnant black mums have much less access to good antenatal care than white mums, mainly down to the poverty, not just poverty. Growing up in a poor area means that black kids are more exposed to violence because that's what happens in poorer neighbourhoods. They have worse living conditions. So it's a combination of these factors adds to the risk. Why more black young people end up with schizophrenia than white young people.

And yet it's not just about racism, but actually a lot of the things that aren't about the direct racism, about the indirect effects of racism. And this is an illness that's probably more genetic than environmental. But the environment has a very big effect on a very important mental illness.

[00:25:36] Cheryl: That's a really interesting research, but also heart-breaking.

[00:25:41] Paul: Absolutely.

[00:25:42] Cheryl: I think, you know, hearing that makes it just, I think it's incredibly sad that over time this is what can happen.

[00:25:50] Paul: Yeah.

[00:25:51] Cheryl: Interesting that you had that correlation with the Norwegian.

[00:25:54] Paul: Yes.

[00:25:54] Cheryl: So that, helps to say that, you know, these sorts of things do happen, so how can we change that?

[00:26:00] Paul: Absolutely.

[00:26:01] Cheryl: And that's a societal issue.

[00:26:02] Paul: Yeah. And again, these Norwegians in this study were facing a huge amount of racism as immigrants. I guess rather like Eastern European white immigrants, sometimes face in Britain. It's being the others, the outsiders, being a minority, having services set up for others is traumatic and increases the risk of severe mental illness.

[00:26:22] Cheryl: That's really, really heart-breaking. I think it's useful that we have that research. It's what we do with it now.

[00:26:28] Paul: Absolutely.

[00:26:29] Cheryl: Which comes back to what we are doing here at a university level. Thinking about racism in education. How can we change this? How can we protect our students? How can we protect the environment in which we're in to ensure that we don't have these sorts of issues impacting in the future.

[00:26:47] Paul: Yeah. Most of our graduates won't be in poverty after they've graduated because they're going to be doctors. But actually they're going to be working with patients who are facing all of these risk factors, and they need to understand that and they need to do something. And we need to help advocate as people with loud voices, the importance of reducing inequality in this country and reducing racism.

[00:27:10] Cheryl: Absolutely. Absolutely. I think that's really important.

I could almost say, let's just stop there because that was a really excellent way to sum up some of what we need to do. We have talked about a lot more.

Do you have any top takeaway points that you would like to kind of highlight from our discussion today?

[00:27:30] Paul: Yeah, I suppose the first one is listen to your students. Actually, yes. As teachers in a medical school, we know a lot more about a lot of things than our students. We know more about educational theory and I know more about adolescent psychiatry than most of the students do because I've been working in it for years and years. But actually there's lots of further areas that are really important that students know about, and we need to let them educate us rather than see education as a one way process.

To do that, we need to create an atmosphere where the students feel able to criticize us or else we won't realize that we have this problem. So listening to students and setting up the environment where we listen is really important. I think it's about, and I guess linked with that is being open to new ideas. Again, racism's, something I hadn't thought much about because I thought, well, it's not such a big problem as it used to be, but it's there. It's still a big problem. And by listening, I learnt that.

I guess then terms of what we do about it, it's important to think really carefully about these things and actually think about all the ways that we need to work on them. So dealing with racism hasn't just been about, well, let's teach about it better. It's been the other things, it's how do we train our staff properly, train our students, how do we keep students safe? And by having a group of people, including students thinking about these things, it means we do it better and more comprehensively. So that's very important. I think that's really important.

 And I'd say that's the main things that I'd take away. And this doesn't just apply to racism. Actually applies to everything. There's a lot of other issues. So another huge topic at the moment, which we're talking about is sustainability. And we have, one of our faculty is very passionate and knowledgeable, but some of our students are, and they're being really helpful in educating us as senior leadership and helping us to think what to do about that other hugely important issue.

[00:29:28] Cheryl: Yeah. I think that's really helpful. Thank you. And I think it's great to hear that we can learn from one another. And how important it is to listen to students and that they have a lot to offer us.

[00:29:40] Paul: Yeah.

[00:29:41] Cheryl: Just as much.

So thank you, it has been a really interesting conversation. Really sad in a lot of factors, but also heart-warming to know that we are making changes and things are improving together, which is really important.

So Professor Paul Wilkinson, thank you once again for such an engaging discussion today. I think we've all learned lots of different aspects of what's going on and how we can improve things. I know we're going to be talking to you again in the future because you have a lot to offer us. So I will be looking forward to that next discussion as well. But for now, thank you so much for today.

[00:30:23] Paul: Great. Thank you. Goodbye.

[00:30:26] Cheryl: If listeners are interested in learning more about the work that the University of Cambridge Clinical School has been doing to reduce racism in medical education, or need advice on how to improve their own medical school, please contact us via the CUMEG website.

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