Implementing an Antiracist Curriculum for Pediatric Residents with Dr. Orquidia Torres

Pittsburgh’s Inequality Across Gender and Race 2019 (PDF)

Antiracist Curriculum Implementation for Pediatric Residents | NIH National Library of Medicine

Amachi Pittsburgh

Anti-Racism Statement | Pitt Pediatrics

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Amanda Poholek: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm your co-host, Amanda Poholek, Assistant Professor of Pediatrics.

Dr. Arvind Srinath: And I'm your co-host Arvind Srinath, Associate Professor of Pediatrics.

Dr. Poholek: Today our guest is Orquidia Kiki Torres. Dr. Torres is an assistant professor of pediatrics at the University of Pittsburgh School of Medicine. As a clinician educator, director of medical student and resident education and Adolescent Medicine Fellowship program director, Dr. Torres works closely with trainees to teach them the skills to care for adolescents and young adults, especially underserved youth.

Her clinical expertise includes menstrual disorders, long-acting reversible contraception, contraception for medically complex patients, mental health and eating disorders. Dr. Torres's current research is focused on the development and evaluation of an anti-racism curriculum for trainees. And that's the topic for our program today, is anti-racism curriculum. Thank you so much for being with us, Dr. Torres.

Dr. Orquidia Torres: Thank you for your introduction.

Dr. Poholek: So we would love to start by just having you share your path for how you got to Children's and yeah, a little bit about your background.

Dr. Torres: All right. Well, I'm originally from New York City and I spent my entire life in New York City. And as the New Yorker, I did not know where Pittsburgh was on a map until I came to Fellowship. But I did all my med school and pediatrics residency in New York and then I came here for fellowship. And part of that was I was looking for a fellowship that would really hone my skills in adolescent medicine, but make me a better physician.

And when I came to the interview for Pittsburgh, even though it was my first time here, I really felt that in the interview process and I felt at home with our division in adolescent medicine and that's what made me want to come here. And then I got accepted here. And from there I spent my fellowship here and got more training in adolescent medicine and medical education and then I went back to New York and then came again.

Dr. Poholek: Fantastic. So you're a physician, you're a clinician educator, and you're heavily involved in anti-racism curriculum for trainees. So tell us a little bit about what that is and how it's implemented sort of into your job and into your practice.

Dr. Torres: Yeah. So this started in 2020. And I am not the only person in the anti-racism curriculum. I will name off some of my colleagues that were part of this. So Nicholas Soko, who is now a fellow with us in Adolescent Medicine, a third year fellow, the former chief Braveen Ragunanthan, our other faculty member in Adolescent Medicine Ana Radovic. And we kind of got together in 2020.

We really wanted to make a difference for the Children's hospital because of all the racial inequities that were going on at the time. So at the time, the death of George Floyd was just really a national event and really took a toll on many people.

And then we also wanted to make a difference within Pittsburgh because of the 2019 Inequality Report that was published. And seeing that as a black Hispanic woman, it made me question why I came back, but not enough for me to leave. It made me push me to really want to make change in here so that I can stay here and make it a better place for other young women coming up in Pittsburgh.

Dr. Srinath: So you used that report as a vault, those facts as a vaulting point to create this, to be honest, incredible curriculum. Can you talk about what the components of this curriculum are and how it was implemented in terms of which trainees you decided to start with and how it's grown?

Dr. Torres: Yeah. So when we all met, we were kind of starting from scratch and we were trying to figure out how to really put this into play. And we thought the easiest way to go about this because Nick and Braveen were both chief residents at the time and had access to the residency program, had access to Noon conference. And that was an easy target for us to start with. They had buy-in from the residency program directors and even from the residents.

And so we figured, "Okay, if we're going to start something from scratch, let's try it with the residents and see how it goes." So it was more of a pilot. But for us it meant all four of us meeting together to really figure out what was it that we were going to teach the residents, what did we want them to come away with, and is this something that could branch out to other trainees, even other faculty members within Children's or even beyond that.

And because the 2019 Inequality Report was the driving force for this, we kind of based our topics in the curriculum on the highlights from that report. So we broke down the curriculum within five sessions. And so we targeted the topic of racism in schools, racism in healthcare, in employment, in the juvenile incarceration, and community housing and transportation.

And we really wanted to show the residents a different side of Pittsburgh so that they understand what our patients are dealing with and be able to better care for them. And so it wasn't a matter of just showing, "Hey, these are the inequities going on in Pittsburgh." It was, "How can we really help these patients knowing that we have these inequities in Pittsburgh and how can we do that as a pediatrician?" Because sometimes it feels daunting, like all this is going on, can you really make a difference in a clinical visit, in an inpatient visit and beyond that? And we wanted to show them small ways that they can make change.

Dr. Srinath: That's amazing. I really appreciate you showing not only just the healthcare side, but that's really key point, perspective. And speaking of perspective and learning perspectives too, from a resident standpoint, I understand you've had some really novel ways of the actual format of these sessions. So can you describe that?

Dr. Torres: Yeah. So because we started with the residents, while Noon conference was an easy target, we had some pros and cons with that. And so it meant that we only had an hour each session when we did those sessions with the residents or less time depending on when the time started. But we wanted to not only give them the session to learn about the topic, but for them to be able to discuss these topics with us.

And so we had some free time in the middle of the session and towards the end for them to talk about what this means to them, talk about how this impacts their patients, maybe they're already dealing with this with their patients and how they can best make change for those patients and what they can do to teach other people how to make change. And so because of this, it meant the faculty wanted to start making a change too because they saw that the residents were learning this and that led to the dissemination of the anti-racism curriculum to other members within Children's Hospital.

Dr. Srinath: That's fantastic.

Dr. Poholek: Very fascinating. Yeah. I wonder if you could actually give a little more background on this 2019 report. Who was the report run by, who was the target audience for the report, and kind of what were the key findings of the report that really were the basis for this sort of conversation to happen that's developed into this amazing curriculum?

Dr. Torres: Yeah. So actually Dr. Miller from Adolescent Medicine, so Liz Miller was part of that workforce that came together to make this report. Her and other scientists, researchers pulled in data across Pittsburgh and wanted to show the city of Pittsburgh what's going on in Pittsburgh. And that meant maternal mortality, what the kids were dealing with, the employment structures and how the wage difference was going on, the amount of children who were referred from school to the jail system for minor things.

And so all of that is in that report and it touches on these inequities and it was published online and beyond. And so people were able to find that report even without even telling them and including some of our trainees who were applying to Children's. And so I made it part of my process as a fellowship director to really touch on it, even if they didn't bring it up, to let people know that while this is going on in Pittsburgh, we're trying to make a difference.

Dr. Poholek: I'm curious, since that report was run before COVID, before George Floyd, do you feel like if we were to do the report again now, what would be different? Do you think there would be any areas of improvement or would it also just sort of demonstrate sort of, and I feel like those situations that happened over the last three or four years perhaps maybe only enhanced or further widened gaps, where do you think we are now, if you had to guess in comparison to what that report showed us in 2019?

Dr. Torres: I think because of COVID, I think we're probably at the same level, if not worse, because COVID exacerbated that.

Dr. Poholek: Right.

Dr. Torres: Tremendously. And that's why it was important for us to talk about this with the residents and then from there disseminated to the faculty members because it did take a toll and our patients did not believe us when they were coming to see us. And it just further expanded those inequities. And so the racism in healthcare was definitely appropriate to talk about with residents because we were seeing it at firsthand.

Dr. Poholek: Yeah. Yeah.

Dr. Srinath: So first of all, I'm just astounded at the fact that you took this idea, you implemented it and you disseminated it in a novel way too. And granted, while sadly the state hasn't changed, what has been the reception from the people who have received this curriculum, [inaudible 00:10:14] the residents?

Dr. Torres: The residents really enjoyed it. And the year that we did it from 2020 to 2021, we were able to implement guest speakers to come to talk to them about what's going on in Pittsburgh with the transportation system and work that they're doing to try and make transportation costs fair. We had another guest speaker coming from Amachi Pittsburgh to talk about what they're doing with youth who have family members who are incarcerated.

And we had them talk about books that were part of the curriculum and they really enjoyed having the space to talk about this. Because this was an opportunity to, even if it was happening before, it wasn't really specified as this is, "We're going to spend this moment to talk about anti-racism and ways to help our patients and ways to even help our colleagues."

And they really enjoyed that time and wanted to continue that. And because of that, we were able to, even after the curriculum was done, continue Noon conference slots so that we can talk about anti-racism. And so we don't necessarily talk about the same topics, but we are talking about topics within that realm, just not necessarily focusing on Pittsburgh.

Dr. Srinath: That's fantastic. So you basically started a propeller and now they're asking for topics and you're finding different ways to give those sessions. How has this curriculum been disseminated to other trainees outside of the residency?

Dr. Torres: Yeah. So Peds Hospital Medicine was actually the first group to want to take it on outside of the residents. And so I met with them and we spoke about ways to incorporate this in their normal learning time for their division, and we gave them the entire curriculum. I was part of their meetings to help answer any questions if there were in the curriculum. And then from there we kind of branched out to other divisions. So General Academic Peds also [00:12:00] receive this, Emergency Medicine receive this, the Children's Fellows receive this as well, and Adolescent Medicine of course.

Dr. Srinath: So you've disseminated across residents, fellows and faculty now, which is, that's amazing.

Dr. Torres: Yeah. And most recently the advanced practice practitioners, so the APPs.

Dr. Srinath: You've really been broad. That's fantastic.

Dr. Torres: Yeah.

Dr. Poholek: I'm curious, as you kind of reach all these different groups of people at different stages of their career, have you had to adapt the curriculum at all-

Dr. Torres: Yes.

Dr. Poholek: ... to these different groups of people based on sort of their prior experience and what they may mentally or sort of in their thought process need to change versus sort of new people coming into medicine and their perspective or sort of a more fresh idea of things?

Dr. Torres: Yeah. So we actually kind of tweaked it even from the residents onto to faculty. The content was the same, but how we delivered it and the questions that came up and the discussion that came up were a little bit different. So for the residents, after we did the main core topics of the curriculum, we actually met with them again to talk about how they feel diversity is impacted in Children's in positive ways, negative ways, whatever ways.

And we were able to use that as a driving force to provide that to the Department of Pediatrics and give them what's going on, what the residents are feeling is important for drivers for change. And then when we gave this to faculty, depending on the division, some divisions were comfortable speaking about it, like Adolescent Medicine, we're always used to talking about uncomfortable topics, and they really enjoyed this.

And we incorporated our entire division, not just the providers, but the researchers as well. And that led to enormous amount of discussion and hearing different viewpoints from the research side, from the clinical side. And when we gave it to other divisions who were not as comfortable talking about this, sometimes they would want to discuss, sometimes they wouldn't. They just want to hear the information, and that's okay. We did it according to what they want us to do.

Dr. Poholek: So now that you've been doing this a couple of years, I'm curious, how do you evaluate its effectiveness and then how do you determine things that may not be working and then use that information to try and think about the future? What are the goals going forward?

Dr. Torres: Yes. So we did evaluate with the residents.

Dr. Srinath: Yeah.

Dr. Torres: And part of it was because this is our first time doing it, and we were able to see improvements in their knowledge and the way they practice in their clinical encounters because we wanted to teach them different ways to approach these topics. And so we saw that change when we did the survey and the evaluation. And then we also evaluated some of the groups, Adolescent Medicine was evaluated, and Peds Hospital Medicine was also evaluated to see if there's a difference from using this curriculum.

Now, it's not the only curriculum that I suggest people should be part of. I think there are plenty of other opportunities across UPMC and across Pitt that people should involve in their division or in other trainees to be able to learn about anti-racism. But the people who did use it, they definitely benefited from it because it focused on Pittsburgh.

And going forward, I think different ways that we can evaluate depends on how we actually embed it in Children's. So I think, obviously I'm just one person, or even my group, we're just poor people, and the best way to really disseminate this going forward would be to record it. And so that's my eventual plan is to record this so that everyone can be part of this in some way.

And then have a group of facilitators so that if that division wants to talk about this more and have a facilitator lead this who's comfortable talking about these topics and really getting into the nitty-gritty of what's going on with anti-racism, we can have that person go there and really lead that conversation for them. Or if there's a DEI champion in that division that wants to take it on, we can help them learn the curriculum and be able to facilitate. So that's what our eventual plan is. Hasn't come up yet, but eventually we'll get there.

Dr. Srinath: That's exactly what we were thinking of is where are you going next and you're starting to propel it, you're getting suggestions for where to go, but how can you even broaden who can be the teachers? Right? And you're already clearly thinking about training the teachers.

Dr. Torres: Yes.

Dr. Srinath: Have there been similar initiatives across the country for different cities that you're aware of? Because I feel like this is novel.

Dr. Torres: Yes.

Dr. Srinath: Yeah.

Dr. Torres: So I think different institutions are showing their trainees and faculty members different concepts of anti-racism and diversity, equity, inclusion work. But I don't know that places are really focusing on their particular city, or if they do, maybe it's just one session and not based off a whole report.

The Pittsburgh Inequality report really compared Pittsburgh to 89 other cities, and that's what helped us to use this curriculum. And I don't know that there's that similar type of report for other cities. Maybe there are, and I think it would be a good thing if there was to be able to incorporate that for other cities and trainees.

Dr. Srinath: That's amazing. I mean, yeah, it's a great setup here for showing what can be effective. And we talk about feedback, we talk about evaluation, but in your years with this curriculum, have you seen proxies demonstrating, "Guess what? We've had an impact on the residents?" And if so, what types of proxies have you seen? Not necessarily a test, but...

Dr. Torres: No. No. I mean, I think without a survey and without doing the research part of this, I think the change that we're seeing is that the residents are more comfortable talking about this with patients or just talking about it in general amongst themselves, with other faculty members, and feel ready to go to other people to bring this up if it is a problem. Even with us in Adolescent Medicine, we easily bring that up if it comes up.

Many of our patients are dealing with racial inequities, social inequities, and so we talk about that as part of our social history and how that impacts their health. And I feel like those residents are now able to bring that same knowledge and expertise into other settings and to be able to bring that up with attendings. And that's what led to attendings wanting to learn this.

Dr. Srinath: That's huge. That's huge.

Dr. Poholek: I'm wondering if there's one aspect of this that's been harder to implement than others. If there's been one area that seemed easier for people to talk about and one part that's just really harder.

Dr. Torres: Oh, yeah.

Dr. Poholek: And trickier. And is it just one of those things that we just have to keep talking about it so that it feels easier or are there other things that we can do to sort of make that feel more comfortable for the educators?

Dr. Torres: Yeah. I think for racism in healthcare, I think some people feel like it's easy to talk about because we see it. We see it with our patients, we see it in some of our colleagues and what they're dealing with, but it's also uncomfortable to deal with and to talk about. And so for some people, that's an easy conversation.

They can talk and tell you about all the things that they've seen and witnessed and how they're impacted by it, but others may not want to talk about that and shy away from it because they're not ready to talk about that in any kind of space. And our motto for all the sessions that we have done for anti-racism curriculum is if you feel like you need to step out [00:19:30] and take a breather, go right ahead. Because we do it as the facilitators because it is hard to talk about.

Even if it's something that you talk about all the time, it is hard to talk about and takes a toll. And so if you need to take a break, you need to step away, that is okay. And then when you are ready to come back, because it is a lot of work and to change something that has been going on forever and now all of a sudden we're going to try and change it is going to take a lot more people and a lot more work.

Dr. Poholek: Oh, sure. Yeah.

Dr. Torres: And so it can be hard to talk about that within medicine and really drive that, especially if only a few people are doing that.

Dr. Poholek: Yeah. And I think we kind of touched on the idea of evaluating residents and how it's changed their practice. I wonder if there's a way to evaluate it from the patient experience. Do they see a difference? Do they feel a difference?

Dr. Torres: Yeah. I think that'd be a great way to, obviously, if I had more time, to be able to see how this is impacting their care, if they feel like that provider is now more caring or if they're hearing their needs because of this training.

Dr. Srinath: That's amazing. That's amazing. I had another follow up question about unconscious bias. Right? Is that something that discussions have been brought up pertaining to or is that something that you see in the future or...

Dr. Torres: Yes. So it obviously wasn't a part of the original anti-racism curriculum, but the sessions that we like to have for the residents and even with Adolescent Medicine, as we continue our focus on anti-racism, we do talk about that. And for the residents when we have new conference sessions slotted just for anti-racism, that is one of the topics we hope to bring up in the future.

Dr. Srinath: That's amazing. So just to summarize, Dr. Torres, this curriculum is hugely needed and it's a great example of how you saw something. You saw something that was devastating, right? In terms of facts. And you used it as a pivot point to help enrich the learning environment here for all of our trainees and faculty and healthcare providers too. We really appreciate what you've done and look forward to seeing how this curriculum grows over the future too.

Dr. Torres: Thank you.

Dr. Poholek: Yeah. Thanks so much for being here today and sharing this work with us and for continuing to work so hard to really bring about these critical changes.

Dr. Torres: Thank you. Thank you for having me.

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