All right, I'd like to thank you for attending today's webinar, Practicing Culture, Competence, and Humility in Epilepsy Care Setting. Please note that this webinar does offer continuing education credit after completing the evaluation. You will be taken to the evaluation immediately after the webinar. You will receive an email with the on-demand version when it is available. Before we get started, I would like to take a moment to acquaint you with a few features of this web event technology. At any time, you may adjust your audio using any computer volume settings. Should you encounter any audio issues, refer to the meeting information pod for further instructions in reaching out to our support team. On the right-hand side of the screen, you will see the text Q&A window. There is a large window which will hold all of your sent messages. In the smaller text box at the bottom, you will type in your questions. To send a question, click on the text box, type your text, and when finished, click the send button. All of the questions you submit are only seen by today's presenter. Questions will be responded to in the order in which they were received to be addressed at the end of the presentation. I would like to introduce today's moderator, Dr. Elaine Kierkegaard-Colophos, the Geisel School of Medicine, Dartmouth Health, and AES Online Education Committee member. Great. Thanks so much. Yeah. Welcome, everyone. We're excited to have you with us here today for today's webinar. I'll start with disclosures. So, Dr. Felton has no disclosures relevant to this session, and I have grant-funded salary support from the Centers for Disease Control and Prevention. This webinar education is supported by a cooperative agreement grant from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. The learning objectives for today's webinar include defining cultural competence and cultural humility, and helping to grow understanding around why cultural competence and cultural humility are important in creating equitable and inclusive healthcare services and systems. Dr. Felton will also guide further learning around identifying, examining, and challenging cultural assumptions, values, and beliefs, and discuss methods to redress power imbalances in epilepsy care settings. It's my great pleasure to introduce to you Dr. Elizabeth Felton, who is an assistant professor of neurology and biomedical engineering at the University of Wisconsin School of Medicine and Public Health. She specializes in epilepsy, and her clinical interests include ketogenic therapy for adults, epilepsy during pregnancy, neurostimulation, and pediatric-to-adult transitions. She is the UW Health Ketogenic Diet Program Director and Women's Epilepsy Clinic Co-Director. Dr. Felton is a graduate of the American Academy of Neurology Diversity Leadership Program and is a UW-Madison Department of Neurology Diversity, Equity, and Inclusion Officer. With the AAS, she is current co-chair of the Fellows and Junior Investigators Professional Development Committee and a member of the Diversity, Equity, and Inclusion Committee. She has previously served on the AAS DEI and Gender Diversity Task Forces, and she is passionate about reducing neurology health disparities and improving diversity and representation in the sciences. Elizabeth, I'm going to turn it over to you. Thanks so much, Dr. Felton. Great. Thank you so much, Elaine, for that really nice introduction, and thank you to the AAS for inviting me to speak on this topic. I'm really excited. Let me move on. Okay. So, before we get into a discussion of cultural humility and competence, I want to briefly review some statistics. I think we all know in our day-to-day interactions that the U.S. population is becoming increasingly diverse. Here is some data from the U.S. Census comparing statistics from the 2010 and 2020 Census. So, the U.S. population has... Let's see here if I can... Here we go. ...has grown by about 23 million, and the diversity index, which is the probability that two people chosen at random will be from a different race or ethnic group, has increased by about 6%. And then between 2020 and 2010, we can see that while white non-Hispanic people still make up the largest racial group, but the percentage has decreased. While the percent of Hispanic Latino has increased and the amount of Black people in the U.S. has remained about the same. However, physician diversity is lagging significantly behind the increasing number of non-white population in the U.S. This means that many of us, physicians and other healthcare providers, will be caring for a majority of patients who come from a different cultural background than our own. And so, I want to briefly highlight some demographics specifically for U.S. neurologists. This data is from the American Academy of Neurology 2020 Insights Report, showing results from a membership poll that occurred in 2008 and 2019. There's demographic data for all members, which is a global cohort that's on the left side, and U.S. members only on the right. I'm going to focus on that part. And so, we can see that there has been more progress in some areas than others. So, for example, the amount of U.S. women neurologists has increased by about 10%. So, we're not quite at 50% yet, but I know I can see in my department, and I'm sure you all have seen that, there is an increasing number of women neurologists. However, the increase for racial and ethnic groups that are historically underrepresented in medicine increased by a much smaller amount. And so, I'll specifically call out that for Hispanic or Latino, which increased a couple percent, Black or African American, which only increased about 1%, and American Indian or Alaska Native, which actually decreased between 2008 and 2009 in terms of representation of U.S. neurologists. And so, what makes these numbers even more striking is when you compare them to the U.S. population, which I feel that at minimum, we should try to reflect in our numbers. And so, this is race ethnicity data for the U.S. population and U.S. neurologists in 2019. So, even though Black or African American people, the estimate was about 13% of the U.S. population in 2019, we made up less than, sorry, 3% of U.S. neurologists. And so, I'd like everyone to consider that for a moment and realize really how much work we still have to do to increase these numbers. I've also highlighted the data for American Indian, Alaska Native, and Hispanic Latino at the bottom. And so, we really need to work to get more numbers of neurologists and other healthcare providers that more adequately represent the populations that we're serving. And I don't have epileptologist specific data, but I suspect it is similar. And so, there really is a great need for understanding and practicing cultural humility and cultural competence because most of us will have a patient population with a different cultural background than our own. And this here only highlights race and ethnicity data, but there are many other potential types of cultural differences between neurologists and other healthcare providers and the patients that we work with. So, let's start out with some definitions. So, in this talk, we're focusing on cultural competence and cultural humility, but I will acknowledge that there have been many similar but nuanced frameworks that have been discussed over the years. So, some that you may have heard of include cultural awareness, cultural intelligence, cultural sensitivity, and cultural dexterity. Cultural competence emerged as a theoretical construct in the 1980s and then was developed into an accepted framework for multicultural practice in the 90s. And the definition has evolved over the years as it's been applied to different settings, including medicine. And in medicine, as there started to be greater awareness of the need to educate physicians and other healthcare providers about working with people from different cultural backgrounds, we started to see more discussion of cultural competency as a key part of medical education. And so, one definition is the ability to understand, appreciate, and effectively interact with people from diverse cultures. And it involves recognizing and respecting cultural differences, as well as adapting one's approach to care, to meet the needs of each unique patient. I'm sure we're all familiar with some version of this definition, and it's been around really for a long time. But in 1998, Drs. Turvalon and Murray-Garcia published this editorial in the Journal for the Healthcare for the Poor and Underserved. And it discussed and challenged the term cultural competence and suggested using cultural humility, specifically in the context of physician training outcomes. They called for distinguishing between the two and felt that cultural humility, which I'll define in a minute, was a more suitable goal in multicultural medical education. And so, this is what they said about cultural competence. The traditional notion of competence in clinical training as a detached mastery of a theoretically finite body of knowledge may not be appropriate for this area of physician education. And so, what they meant is that they did not want cultural competence to be seen as something that could be sort of completed or checked off by taking a course or series of training sessions. And then people feel like there's an endpoint or a point of mastery that can then be assessed in medical education, similar to other types of competencies that we have in medical education that are assessed by taking the MCAT or board exams, for example. But what they're saying is that there's really not an endpoint to this. And so, what they reframed cultural competence and proposed that it could be expanded and better described as cultural humility. And so, their framework of cultural humility focused on three parts. So, lifelong commitment to self-evaluation and self-critique, redressing the power imbalances in the patient-physician dynamic, and developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations. And so, I'm going to go in and talk about some of this through the talk today. And I do want to point out that although some of this language is specifically, you know, it's saying patient-physician dynamic, I want to stress the importance that this applies to all types of healthcare providers, ranging from nurses, advanced practice providers, behavioral health specialists, neuropsychologists, dieticians, et cetera, pharmacists. So any person in sort of the healthcare continuum that is working with patients living with epilepsy. And so, you know, I want to talk about why is cultural competence and humility important. So they are essential in creating equitable and inclusive epilepsy healthcare services and systems that promotes effective communication, trust, respect, access to care, and cultural sensitivity. So just to give some examples, you know, understanding the communication styles, languages, and norms of diverse populations is important. It's important to respect and honor patients' cultural values, beliefs, and preferences because this fosters a more patient-centered approach to care where patients' individual needs and preferences are considered in the decision-making process about their treatment plan. And then being sensitive to cultural factors that can impact a patient's health, such as dietary preferences, religious practices, or traditional healing practices. If we don't ask about these things and understand these things, we really don't understand our patient. And the bottom line is that patients are much more likely to trust, engage with, and follow treatment recommendations of healthcare providers who demonstrate cultural competence and humility. And patients pick up on this. They sense these things from their provider. And so in these next few slides, I'm going to briefly expand on health disparities and health equity. Oh, sorry. So, you know, it's, so these things are important to address and reduce health disparities. And this leads to better quality of care for all patients. And so this is not just something that is going to help a limited subset of our patients. It is going to be practicing these kind of fundamental practices will help all of our patients. And so now I'm going to go into a little bit more about health disparities and health equity. So health disparity is a particular type of health difference that is closely linked with social, economic, and or environmental disadvantage. And they adversely affect groups who have systematically experienced greater obstacles to health based on one or often more of the factors listed here. And some of these are characteristics that are historically linked to discrimination or exclusion. And your mind may consciously or unconsciously try to think of ways to explain these differences that don't involve bias or racism. But unfortunately, these healthcare disparities persist even when corrected for factors like socioeconomic status, health behaviors, and differences in access to care. So even when correcting for all of those things, there are disparities in people from different racial and ethnic groups, religions, etc. And we really need to acknowledge that in order to make progress. And so I want to just show what this looks like in the field of epilepsy. I'm going to show just about 10 or 12 screenshots of articles that have been published over the last decade or so about disparities in epilepsy care. I'm not going to discuss each. But I just want to very quickly give you a sense that this is being talked about, this is being published, where people are looking into this, and we really need to do something about it. And probably these articles only scratch the surface of the actual problem in terms of health disparities in epilepsy. So this is one about disparities in the nationwide distribution of epilepsy centers. So where they are located versus where the patients are, and how far they potentially have to travel to get there. Socioeconomic disparities in SUDEP cases. Health disparities in families living with epilepsy are significant and linked to socioeconomic status. Facets of health disparities of epilepsy surgery and gaps that need to be addressed. So this one talked about the different types of health disparities that are related to patients receiving and being referred for epilepsy surgery, and how some of these can be specifically addressed. Delays and disparities in just receiving a diagnosis for epilepsy, looking at Medicaid data of when the patient is first documented to having a seizure, to when they actually receive a diagnosis of epilepsy. There's disparities there. Disparities, again, in epilepsy surgery. Disparities in enrollment in clinical trials. This is probably not a surprise. We heard about some of this with, for example, recently with COVID clinical trials, and problems in having some disparities in the enrollment in those studies. Burden of chronic and acute conditions. And symptoms in people with epilepsy. This is from the CDC morbidity and mortality weekly report about barriers and access to care. Socioeconomic disparities in care. Health disparities in pediatric epilepsy. And then a review among health disparities among rural people living with epilepsy. So this, like I said, I think scratches the surface, but I just wanted to give you a sense of some of the things that are being published in this area, in our field in particular. And so I want to turn briefly to talk about implicit bias. So I could give a whole talk on implicit bias, but put simply, explicit or conscious bias is out in the open. You're aware of it, and people around you probably are too. So that would be like overt racism. But implicit or unconscious bias is below the surface. And you probably aren't aware of it unless you've done some work to uncover this. But it's still a part of you, and it affects your actions. And it can be very bad for our patients. And this can lead to health disparities. And so it can literally be deadly. And there we go. Studies have shown that, just as an example, Black patients are less likely to receive rehabilitation support following mastectomy for breast cancer, prostatectomies for prostate cancer, post-cancer treatment, surveillance care, surgery for lung cancer, inadequate pain control. I'm sure we've heard about that in terms of the ER settings and patients from certain groups, including Black and Hispanic or Latino not receiving adequate pain control. And then referral for epilepsy surgery. And the list goes on and on. And I'd like you to think for a moment about this issue from the patient perspective. The caption for this image here reads, the emotional toll of negative experiences can lead Black women to distrust doctors. And eventually, some people just stop going. And so these implicit biases that we hold can affect health care provider behavior. And the patients perceive this bias even if you don't. And so you may think, like, I'm treating all patients the same. But in reality, you may not be. And patients who experience or perceive this bias then may have less trust, adherence, compliance, satisfaction, and willingness to return for follow-up. And so when we think about this, we have to ask what role we might be playing when a patient says these things, or sorry, when we say these things about a patient, that they have poor medication compliance. They seem to distrust us. They don't listen to our advice. They never follow up. You know, we, I think probably we've all been in settings where either we have said that or other people that we work with have said that. And, you know, maybe next time reflect when you're saying that or hearing other people say that and thinking about could there have been something in the interaction between the patient and either yourself or another health care provider on the treatment team that have actually led to this outcome. And also important to look critically at our treatment plans and determine, are we actually treating all of our patients the same? We may think that we are, but if we were to actually look up, you know, a QI project on all of the charts of patients that we've seen in different ethnic groups or different cultural backgrounds, are we actually offering the same level of care to all those patients or not? And so now I want to turn briefly to health equity. And so health equity is the attainment of the highest level of health for all people. And achieving it requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities. And, you know, there's been a variety of graphics that have been used to depict the differences between equality and equity over the years. There used to be one with some people along a fence looking at a baseball game, and there's been some evolution of that. This is a newer one from the Robert Wood Johnson Foundation, and it depicts equality on the left, is that everyone is getting the same thing, regardless of it's needed or right for them. So, you know, on top, there's a child with a bike that's too big and a bumpy surface, and you can kind of see the other two. And then on the right is equality, where everyone gets what they need, understanding the barriers, circumstances, and conditions. And so this is the key here, is that we, as health care providers, need to have an understanding of our patients' barriers, circumstances, and conditions. And we are not going to find that out unless we have open communication with them, talk to them, ask open-ended questions, and find out what their needs are, and not making assumptions based on, you know, other patients that we've had who we think might be similar. And so, you know, when thinking about, you know, we've kind of reviewed the landscape, and you may wonder where to start. And so going back to the first part of the cultural humility framework, which involves a lifelong commitment to self-evaluation and self-critique. And so here, identifying, examining, and challenging cultural assumptions, values, and beliefs is essential. And so I'm going to go through this slide, and I'm going to try to pause for about 30 seconds after I talk about each part of this. And I'm hoping that you can just briefly think about this. If we were in person and doing a workshop, we probably would spend, you know, at least 15 minutes on this. But I do hope that by the end of this talk, you will have thought a little bit and done a little bit of self-reflection. And so we'll just take a short time for that while we're here. And so the first thing is self-evaluation. So first, before you can be aware of other people, you need to have an awareness of yourself. And so how do you describe your ethnicity, race, religion, gender, sexual orientation, et cetera? What are some of your most closely held values? And if you were in a patient situation, what would you want healthcare workers to know about you? And so I'm going to give everyone about 30 seconds just to ponder that. Okay. And then the second step is self-reflection. So what are some of your own cultural assumptions, values, and beliefs? And what are some of your own implicit biases? And so you may not know the answer to the second bullet unless you have done some intentional work in this area, such as taking an implicit association test. But maybe just let's sit for, you know, 30 seconds again and think about these things, reflecting on your own assumptions and biases. Okay, and then last, I'd like you to reflect on some of your past clinical encounters and ask yourself, were there any cultural assumptions that may have played a role in your interactions? And so maybe thinking about some clinical interaction that didn't go well or where afterwards you felt like there was something wrong, thinking about were there any assumptions that you carried into that with you that may have played a role into that interaction? And so let's, this is the last one. Let's take 30 more seconds on that. Okay, so thank you everyone for hopefully playing along with that. And I hope that you'll give some more thought to those later. So moving on, I wanna talk about some examples of assumptions that maybe you or others sometimes might make in a clinical encounter. So you may assume that a patient speaks a different language because of their name or how they look. You may assume that they won't be able to afford their anti-seizure medication because of how they look, their occupation or their insurance, or the opposite. You may assume that they are wealthy and won't have any trouble following the treatment plan based on cost. You may assume that they may not be accepting of a female healthcare provider because of their religious beliefs. You may assume that if you have a woman in front of you and they say that they're married, you may assume that that is to a man, but in fact, that may not be the case. And due to any one of several cultural factors, you may assume that they won't be quote compliant with a certain epilepsy treatment. So you don't discuss it or offer it. And so examples would be pre-surgical evaluation. We just saw like several publications about that. Ketogenic therapy, I run a clinic for a ketogenic diet for people with epilepsy. And so maybe don't mention it because, well, they just wouldn't be able to do that. And so not even bringing it up. Three times a day, medical medication dosing, or that they wouldn't be compliant with responsive neurostimulation and the things that they would have to do around that, such as uploading data and staying with follow-ups, or again, surprise when they are quote unquote compliant. So all of these things, I think we all do and make assumptions. And I think we just have to give more thought intentionally about why we're having those thoughts. And if that is impacting the care that we are offering to our patients and working to make sure that our care is more equitable. And so when we think about culture, it shapes every aspect of our lives, including our beliefs around health and illness. And patients' cultural backgrounds may impact their perceptions of epilepsy and their willingness to seek and receive treatment. So we need to work to practice humility and provide more culturally sensitive care to our patients. And this can involve asking open-ended questions, listening actively and being respectful of different perspectives as they come up. And so what can we do about this? So in our daily clinical practice. So first, I'll just acknowledge that this takes time. And I know from personal experience, and I'm sure all of you know that time is a limited commodity, but I would offer that it is a total waste of time if we skip this step and that leads to a patient not getting treatment at all, meaning everything else we do is a waste of time. If we're not taking the time to set aside our assumptions and learn about our patients' cultural background, beliefs and values related to healthcare and their perceptions of epilepsy, if we don't know that, we don't really know our patient. And so this can involve asking open-ended questions, listening actively and adapting our communication strategies. And so this all kind of helps us develop a deeper understanding of our patients' needs and concerns. And then you can work together to create a treatment plan that's both effective and culturally appropriate or culturally responsive. So for example, I mentioned I work with adult patients using ketogenic therapy. So it's important for me to know about dietary preferences, some of which may be cultural or religious-based. Or some patients may observe Ramadan where they are fasting from dawn to sunset during a certain part of the year. And so it's important for me to know that and for the patients to feel comfortable discussing that information with me so then I can take that information and best help them with the treatment plan that we're developing. And then talking about adapting the communication strategies. And so this can obviously be written, verbal, but some people learn better by looking at websites and so kind of vetting certain web materials that you can recommend to a patient. Some patients really want to talk to somebody else that also has epilepsy or somebody that looks like them that also has epilepsy. I have a black female patient, maybe she wants to talk to another black woman with epilepsy. And there may be certain restrictions in your healthcare organization about connecting patients, but you can connect them with resources in the community that might be able to make those connections, for example, through the Epilepsy Foundation. And so just thinking about different strategies that you can use to kind of help your patients in this process. And then I just briefly, if you're interested in reading more about culture and epilepsy, here's four that I came across. I have not read all of these, but the first one I actually read when I was in medical school before I had even decided to become a neurologist or an epileptologist and it's really stuck with me. It's excellent and really talks about a child with epilepsy and the interactions between sort of cultural, cultural assumptions and the sort of healthcare provider world. And so I highly recommend that one. Okay, so the next portion of the definition of cultural humility set forth by Drs. Tervalon and Murray-Garcia is to redress the power imbalances in the patient-physician dynamic. And so first step is to recognize that these are inherent in healthcare systems. I'm sure we can all think of several power imbalances that we've noticed in various parts of the healthcare systems that we work in on a day-to-day basis. And really it's inherent in medical education as well from being a medical student and kind of going to residency and fellowship, et cetera. And so it's important to understand which imbalances may exist. And so it could be based on education, position of authority, socioeconomic status, et cetera. And then it's critical to recognize that cultural differences can then further exacerbate these power imbalances. So the power imbalances are going to be there probably no matter what to some extent, but that cultural differences can make this even worse, such as when a patient from a historically marginalized community feels intimidated by a physician or healthcare provider from a dominant culture. And so we need to try to redress these power imbalances in the patient-healthcare provider dynamic. And the goal is to create a more equitable and collaborative relationship between patients, physicians, and healthcare providers. Some ways to do this are, again, effective communication, empowering patients, saying, I want to learn about you, I want to kind of have a relationship here, and then shared decision-making. And so I'm going to do a case now about power dynamics in epilepsy care. I'll talk about the case, and then we'll talk about some of the power imbalances and implications for that and how that can be redressed. So I'll just read this here. Maria is a 45-year-old woman with epilepsy who's been seeing Dr. Smith for several years. She recently experienced a significant increase in seizure frequency and is concerned about the impact on her daily life and her ability to continue working. During her appointments, Dr. Smith has always been the one making the decisions about her treatment plan without much discussion. Maria feels uncomfortable asking questions or expressing her concerns because she perceives Dr. Smith as the ultimate authority on her condition. She has also noticed Dr. Smith often uses medical jargon that she does not understand. And so let's pick apart some of the power imbalances from this case. So one is that there's information asymmetry. So Dr. Smith holds the majority of medical knowledge about epilepsy, seizure management, and treatment options. He's gone to medical school, did residency, fellowship, et cetera. Maria, while knowledgeable about her own experiences, relies on Dr. Smith's expertise to understand her condition fully. So there's this information asymmetry. Decision-making authority. So in previous appointments, Dr. Smith made treatment decisions for Maria, often without engaging in shared decision-making or discussing alternative treatment options. Where Maria has rarely been asked, what are her treatment preferences or goals? I mean, what a simple question. Like, what are you hoping to get out of this? What are you hoping that you will get out of this treatment? And you may be surprised sometimes by the answers that you get to that question when you ask it consistently among all of your patients. Communication barriers. Maria tends to use medical jargon and complex terminology during appointments, which Maria finds difficult to understand. And then perceived hierarchy. So Maria perceives Dr. Smith as an authority figure and feels hesitant to question his recommendations or express her concerns. And so this kind of scenario plays out all day, every day in healthcare settings across the U.S. And I think that we can do some work, some small steps to really help this and have a better relationship with our patients, better outcome, better cultural understanding. So some of the implications of this. So Maria's lack of active involvement in her treatment plan may result in her receiving one that just simply doesn't align with her values, preferences, or lifestyle. You know, she sort of handed this medication to take or next step in care that she doesn't make sense for her. The power imbalance can erode trust in the patient-physician relationship. So she may feel unheard or misunderstood, affecting her overall satisfaction with healthcare. And finally, she may experience anxiety or frustration due to her inability to fully understand her condition or treatment options as Dr. Smith has not taken the time to engage her in shared decision-making. So again, you know, earlier I was talking about, we say about how patients are not compliant and they're not following up. They're not doing what we want them to do. And is it because maybe how we have approached them? And that's why that is happening. And so in terms of redressing the power imbalance, you can initiate open and honest conversations, encouraging our patients to ask questions, express concerns, actively listening to preferences and values, and involve in shared decision-making. And so sometimes at the end of the visit, the patient decides on a next step in care that maybe would not have been my top choice, but it's their top choice, and it's best for them and their situation, and only they know that in that moment. And so I try in most cases to be supportive of what the patient wants to do next. Providing educational materials and resources to help her understand her condition better and acknowledging her expertise in her own life and experiences and respecting her autonomy and making healthcare decisions. So before we go on, I want you to briefly think about this case and the people in it. And so when I was introducing Maria and Dr. Smith, perhaps you conjured up an image in your mind of who those people were just sort of based on even the names that I used, Maria and Dr. Smith. So did you perhaps assume that based on the name Maria, that this patient is Latina, and maybe that she speaks Spanish or maybe even as a non-native English speaker? Or did you maybe make an assumption that she's lower socioeconomic status? None of those things were stated in this case, but our mind has a tendency to make up certain things based on certain things that we see and read. And so being mindful of that and realizing that none of those things may be true. What about Dr. Smith? What did you picture in your mind for that character? Did you imagine that it was a, I did eventually use pronouns he and him, but I did not in the initial text. And so initially were you perhaps assuming that it was a male physician, even though that was not stated in the initial part? Did you assume that they were white? And so that was not stated in the prompt, but just an example of how our mind makes certain types of cultural assumptions. And so it's important to be self-aware and consider how that might be playing out in the clinical setting. And so the outcome of redressing these power imbalances really is more equitable and patient-centered epilepsy care, which hopefully if you're here today, that is your goal to serve your patients in that way. It fosters trust, the patient voice is valued, and the treatment plan is a collaborative effort between the patient and the healthcare team. And so now in just these last couple slides, I would like to highlight a program through the American Academy of Pediatrics, Children and Youth with Epilepsy Initiative. So they identified gaps in epilepsy knowledge and competence around caring for children and youth with epilepsy among healthcare professionals, and so they developed this training as a resource to help build knowledge, capacity, and expertise, and initiate discussion among those who care for children with epilepsy, and it's a free training. The link to it will be in the meeting materials for today. There's four modules, one of which has a focus on cultural humility, so this first one, Caring for Pediatric Patients with Epilepsy Utilizing Cultural Humility, Family-Centered Care, and Shared Decision-Making, and the trainings, or the modules, rather, have a combination of modalities, including a prerecorded webinar, a PowerPoint, and a case study. And so, in summary today, thank you for joining. Cultural competence and cultural humility are important in creating equitable and inclusive healthcare services and systems, and mitigating health disparities. Understanding this requires time, self-evaluation, self-reflection to identify, examine, and challenge these assumptions, values, and beliefs, and this is, again, this is a lifelong process. This is not a mastered it, check it off, I'm done. This is going to be something that is evolving for the rest of your career and the rest of your life. And power imbalances in epilepsy care exist, we need to be aware of them, and determine how we can help redress some of these for optimal patient care. And your efforts really will go a long way to reducing health disparities and improving health equity in people living with epilepsy. So we now, I think, have some time for questions and discussion, would love some discussion on what your thoughts are about this. I'll hand it to Elaine. Oh, we can't hear you. Great, I think I'm back, am I back? Yes. Excellent. Thanks for that really thoughtful presentation, Dr. Felton, and lots for everyone to think about. So maybe as we get going here, people can see there's a box where you can type questions. You talked a lot, Elizabeth, about sort of individually thinking about cultural humility and the way we think and the way we practice and really examining self. I'm wondering if you can talk a little bit about cultivating cultural humility on teams, because so much of what we do is in team settings, either in the clinic or on the wards or in the operating room. Are there some thoughts that you can share with the group around that? Yes. So obviously, yeah, we work in teams all the time. That's like a hallmark of medical education, and I really think this is the job of everybody on the team, but particularly the leaders of the team, to kind of show in their leadership approach, so that this is something that is valued, this is something that is important, this is something that the team is going to take time for and discuss. And similarly, talking in a team setting where people feel open to bringing up concerns, being able to say, oh, I noticed in that interaction with this patient from a certain religious background that maybe we weren't as respectful as we could have been to this, or maybe we should have asked that. And so kind of cultivating this environment where people can speak up and talk about what they noticed and having time set aside to process some of these cultural interactions. And sometimes there's going to be times where there are uncomfortable situations or times where somebody says or does something that later they think that maybe they shouldn't have, I shouldn't have said it that way. And I think it's great if the leader of that team can show some vulnerability in those moments and acknowledging that and owning up to that and having there be some discussion. And so I know that medical education has evolved over the years, and sometimes it's the medical students that are teaching us attending things, some of these things. But I think the people on the attending side need to do some work as well to cultivate these type of environments. Great. There's a question that's come in. How can we do further self-reflection on our personal biases, i.e., how do we find our biases? Yeah, that's a great question, right? Because we don't know it. We don't know it, but it's there. So we can put it in the materials. There's a website that you can go to where you can take a whole variety of what are called implicit association tests. And it involves showing pictures and words and it tests your reaction time to different things and then tells you if you have a preference for certain things. So they have all different types of tests. So they have some based on race, on gender, religion, et cetera. What I have found when people take these is they think, oh, I'm going to game the system or they get a result that's surprising to them and they don't want to believe it. And that's kind of part of the process of self-evaluation is realizing that these biases may be there even if you don't want to believe it, or sorry, I meant to say even if you're not aware of it. And so that's one way, doing some intentional work, looking back at patient interactions and thinking, kind of processing when you're not kind of in the heat of the moment and under pressure and behind in your clinic and thinking about how you approach that interaction and thinking, did I treat all these patients the same way? So unfortunately, it does take time, but again, I want to emphasize that it's time well spent. Sure. There's a comment in here, this is very important, the evaluation of our own unconscious biases and it should probably be part of the medical school curriculum and then brought back regularly through residency and fellowship and as a faculty or provider. And I think you've emphasized that really nicely with us here today and how there's multi-level learning in both directions, I think that can go on around this. There is another question. Are you aware of research related to the influence of time pressures in a neurology practice, for example, and effective expressions of cultural humility? Yeah, that's a great question. I am not familiar of research around that. Are you, Elaine? No, I can't think of it. Nothing pops to mind around the time spent in interactions. I think there's probably literature on that related to shared decision-making. But specific to this, I'm not aware of anything. Yeah. So something for all of us to look into, I guess. Yeah, I mean, that would be a great area of research, actually. Yeah, it would. Let me just ask you about, we've talked a lot about sort of in-person dynamic interactions with providers and patients and members of the team. Do you have any thoughts around cultural humility and charting, like, you know, how we write about patients or how we discuss patients, for example, in epilepsy surgical case conference? Any thoughts around those kinds of contributors and a need to evaluate how we're doing there? Yeah. So I personally do not like putting the race or ethnicity of the patient in the one-liner. When I was in med school, you know, we were kind of taught at that time, you know, this is a 50-year-old white male or, you know, this, whatever. And I personally don't like having that in there because I feel that that immediately puts people's minds in a certain place that may not be appropriate. And so, you know, having the age, I think, is important. Sometimes I don't even know if the gender is always appropriate. In certain cases, it may be, if you're talking about things around reproductive health and the interaction with that with epilepsy. But I think being careful around that. But I think what you're kind of talking about is, you know, some of the language that we use in our notes, some of the kind of coded language that is sometimes used to describe certain things. Here at where I practice, the notes are now open to patients. And so there used to be, I think, some language and some, you know, way that things were described in notes that maybe are now not so much because patients have such easy access to it, which I think in most cases is a good thing. And then in terms of like presentations, yeah, I mean, so when we're presenting a case in our conference, if we're immediately in the opening line, you know, saying that they don't speak English or that they're incarcerated or that they, you know, are, you know, living or that they're homeless or something like that, that may automatically make people assume that certain treatment options wouldn't be for that patient and then perhaps it wouldn't be discussed. Maybe the conversation would go an entirely different way where normally we would be talking about surgery, but now we're just saying, oh, just add another medication or something like that. And so I do think that it would be helpful to be more intentional about that. And I'm not saying that I do that perfectly, but, you know, just some food for thought here. Yeah. So there's a question that's come in that's, you know, sort of asking from an inverse perspective about patient bias and addressing those and how one might approach that if they recognize that. I mean, everyone has biases. So absolutely our patients are a hundred percent coming in with biases and they may be, you know, a patient comes in and, you know, sees me as a black female neurologist, may come in and have some certain assumptions about me or may think that I wouldn't be as good as the older white male neurologist, for example. And so, and certainly that's kind of a whole separate topic for discussion about when patients come in with bias or even overt racism. And so absolutely that is a factor into the equation. I think that, you know, for the purpose of this, we're kind of focusing on what we can do, but they do come in with it. And I think, you know, the other part of that question was, you know, kind of engaging with the patient around that. And I think that that certainly can be done as well. Absolutely. And then I'm just going to ask one more question as we end our time here together around the benefit of getting to know the communities you serve. I know for myself, I'm working in different areas. So starting in Toronto and in Boston, and now I'm in New Hampshire, but, you know, serving people in a different way around the work that we do from all across the country. So getting to know the communities that you're serving, can you talk a little bit about how that might, you know, be beneficial or important in our own growth as practitioners? Yeah, absolutely. That is also part of kind of one of the tenets of cultural humility is, you know, just not staying in your own, you know, neighborhood, environment, hospital, and actually getting out and seeing, you know, where your patients live, what they're experiencing, you know, stopping by, you know, they're just having a better understanding of their circumstances. I do think telemedicine has helped that a little bit. You get a little window into a person's home, which I have actually quite enjoyed, you know, seeing where they live, you know, what, you know, what things look like. Sometimes patients walk through their house during or where they live, their dwelling when they are on the telemedicine visit, and I think that's helpful. But also, you know, I'm involved in our local Epilepsy Foundation chapter here in Wisconsin, and I've gone to some of the epilepsy walks and, you know, seeing patients there and interacting with them and seeing their families and things like that, I think gives me a little window of insight on their experience. And I think that there's really nothing that can substitute for that. You know, you can read all you want about different communities and different things that they're going through, and there can be a bit of a focus on some negative things, but there's a lot of really wonderful positive things, and getting some sense of that and spending time in the communities that we're serving, I think, is really important as well. I agree so much about bridging that clinic to community gap really, I think, is helpful for all of us in learning. Any last thoughts or parting words for us as we wrap up here with just a list of resources for people? Yeah, I mean, I just want to emphasize that, you know, we can all do something towards this. This is something that you could start today. I mean, even me, in my preparation for this, I thought of a couple things that I want to do differently moving forward. And so this is a lifelong thing. I would, you know, just kind of been reading and thinking, I thought of some things that I think I'm going to change and start asking patients. And so this is an evolution. I think we're all in this together. So I encourage you to talk to each other about this, do this work, come to some of the sessions that we have coming up at the AES conference in December. And I'd love to talk with anybody more about this. I think maybe my email is on the next slide, if anyone wanted to talk more or engage about this, I'd love to. Great. Well, thanks so much for sharing your time and your knowledge with us today, and also for being encouraging around this, because I think encouraging one another will help us make gains as an epilepsy community of providers. So thank you so much, and thank you to AES for hosting us today. Thanks.

cultural competence

cultural humility

epilepsy care

inclusive healthcare

implicit biases

diverse backgrounds

health disparities

self-reflection

culturally sensitive communication