Challenges of Teaching about Diversity and Health Equity – by Carlos E. Cortés

A Difficult Conversation about Difficult Conversations forDeveloping Medical Educators of the 21st Century:
New Ideas and Skills
for Adaptable and Inclusive
Learning Environments Conference

February 4, 2022 (Revised, February 6, 2022)

 Let’s start with today’s ground rules.  None.  No rules; no powerpoints.

But three hopes.  That you speak honestly without obsessing about maybe saying the wrong thing, a bane to diversity discussions.  That you contemplate divergent ideas.  And that you reflect openly on your own perspectives by posting comments and questions in the chatbox as we go along.   

So let’s turn to our theme, difficult conversations about diversity and health equity.  Health equity conversations necessarily involve discomfort because they address the idea of group diversity, not just random individual differences.

Group differences are intrinsically difficult to talk about because they involve all kinds of tension-producing elements.  Stereotypes.  Group values.  Systemic flaws.  Contrasting personal experiences.  Language hot buttons.

Yet if we’re really serious about making greater headway on health inequities, we need to embrace these difficult conversations.  The road to health equity is not paved with safe spaces.

I began conducting difficult diversity conversations in 1969 as an assistant professor of history at the University of California, Riverside.  Twenty-five years later, in 1994, at age 60, I took early retirement to become an independent diversity consultant, and the conversations continued.   

Then, in 2020, the UCR School of Medicine launched a new curricular initiative in Health Equity, Social Justice, and Anti-Racism.  The school asked me to come aboard as part-time co-director of this new initiative.  In my classes I announced that my sessions would be “Safe Spaces for Unsafe Ideas.”

This leads to today’s basic question: how can we foster health equity through robust, productive conversations in which participants feel comfortable with discomfort?  I will address this challenge in two parts.  First, an examination of how diversity dynamics inevitably influence these conversations.  Second, a new framework to help you not only navigate difficult conversations, but also lead them.

The Diversity Movement

So let’s start with diversity dynamics.  The diversity movement began in the late 1960’s.  This sprawling, decentralized movement has one basic goal: to change American society by reducing societal inequities that penalize people because of the groups to which they belong, usually historically marginalized groups.

I am currently completing a book entitled “Speech vs. Diversity, Diversity vs. Speech.”  In it I identify five strands of the diversity movement.  These strands overlap, intersect, and sometimes conflict with each other.  The resulting tensions necessarily complicate diversity conversations, including those involving health care.  Let’s briefly review those strands.

First, intercultural diversity, which emphasizes intergroup perceptions and communication.  Interculturalists argue that people should voluntarily modify their speech to better communicate with others.  The premise: that voluntary choices — not speech guidelines — can best create a robust, respectful, and productive conversational environment.

Second, equity-and-inclusion, a product of the 1970’s.  While this strand draws upon the ideas and language of interculturalism, it more explicitly addresses inequities, like health disparities.  Inclusionists are more likely than interculturalists to favor explicitly-stated conversational guardrails.

Beginning in the 1980’s, two other diversity strands diverged from the equity-and-inclusion mainstream.  First was critical theory, whose proponents argue for a skeptical analysis of structures, systems, and cultural practices.  This includes how hierarchies and power differentials distort conversations.

Diverging in a different direction was therapeutic diversity.  In 1980, the American Psychiatric Association officially recognized Post-Traumatic Stress Disorder.  The idea of trauma penetrated the diversity movement.  Not just individual trauma.  Also intergenerational group trauma, which can be triggered.  Ergo, a focus on things like verbal microaggressions and pressure to include trigger warnings before discussions and in course syllabi.

The final diversity strand is known as managing diversity.  This strand is based on the idea of integrating diversity into systems.  It has led to the appointment of organizational diversity officers, such as those now present in most medical schools and many health care structures.  Because of the inevitable collision of diversity pressures and institutional demands, these managers necessarily carry out a delicate balancing act.  When teaching a class or facilitating a discussion related to health equity, we all serve as diversity managers when we try to balance such factors as conversational robustness and personal feelings.    

But while these five diversity strands diverge, they also converge.  In the process, they influence medical school conversations in at least three ways.

First, they make the pursuit of equity and social justice central to health care.  Second, they foster hopes, create expectations, and generate fears about what may occur in these conversations.  Third, they challenge medical school faculty to become more adept at balancing these five diversity imperatives.

Notice, I said “more” adept.  You’re never going to get it perfect.  After fifty years of leading diversity conversations  I’m still learning, because diversityworld keeps changing.  So I always keep in mind the instructive words of Irish playwright-novelist Samuel Beckett from his prose piece, Worstward Ho!:

“Ever tried.

Ever failed.

No matter.

Try again.

Fail again.

Fail better.”

Now I realize that the medical profession does not place a high priority on failing, which is good.  But in conversations about health equity, failing is no sin.  Trying –- and failing –- is how we become better in difficult conversations.  As Aristotle put it, “We become just by doing just acts, temperate by doing temperate acts, brave by doing brave acts.”

     So keep your eyes on the prize.  In professional conversations, embrace the process of failing better because that’s how we make progress toward our goal: health equity.

Facilitating Difficult Discussions

Drawing on this diversity ecology, let’s now examine how we might better lead and participate in these inherently difficult conversations.  To frame my ideas, I’m going to borrow a term from my own school.  As part of our Health Equity, Social Justice, and Anti-Racism initiative, Dr. Adwoa Osei and I have created HEAL: Health Equity Action Lectures.  I’m going to use that HEAL acronym to suggest four steps in learning to fail better in diversity discussions.

H: Help.

E: Embrace.

A: Assess.

L: Lead.

Let’s start with H, Help.  That’s what physicians do: help others.  Medical educators take it one step further by preparing future physicians to become better helpers of others.

Now add a health equity perspective.  We should educate future physicians to help others by reducing health disparities for marginalized communities.  So our first step is to maintain our conversational focus: reducing health disparities.  Unfortunately that doesn’t always happen.

Over my five decades of leading inherently difficult diversity conversations, I’ve observed a penchant for losing focus, getting sidetracked, and building bridges to nowhere.  Particularly in the last two years I’ve been involved in myriad health equity conversations and, yes, the bridges-to-nowhere syndrome often appears.

Last year I attended a health equity conference in which two participants in one of the breakout rooms literally hijacked our valuable hour to wail at length about a supposed microaggression that had occurred in a session the day before.  Back and forth, back and forth about who owed whom an apology.  Others finally interceded and broke off the harangue, pointing out that we had come to this session to talk about helping marginalized communities, not get sidetracked.  But damage had been done.  This bridge to nowhere had squandered much of our valuable time.

Napoleon often reminded his commanders: “If you plan to take Vienna, take Vienna.”  If you come together to discuss health equity, discuss health equity.  Don’t get distracted by erecting bridges to nowhere.  If you’re a conversation leader, maintain the focus: improving health outcomes for marginalized communities.

Now let’s turn to E: Embrace.  Embrace and encourage multiple perspectives, critical questions, and challenging ideas.  Welcome contrarian views on health equity and learn from these challenges.  We need to embrace divergence as well as convergence, because divergence provides new insights.

Most of the health equity conversations I’ve observed have been far too convergent.  I understand.  The human brain loves confirmation.  That’s why we talk about confirmation bias.  To bring robustness to our health equity conversations, we must avoid creating confirmation bias echo chambers.  The best way is to encourage and embrace divergent ideas.

At UCR, Dr. Osei and I immerse students in alternative health care narratives.  In our recent module on disability, one of these alternative narratives came from an extended and illuminating conversation with the president of Riverside’s Blindness Support Services, who portrayed the health care experience from a blind person’s perspective.

We also had students discuss several articles providing differing points of view.  One article presented a social model for addressing disability as contrasted with the medical model.  For our culminating activity we asked students to write a brief reflective piece addressing the following: “What patient-centered care using the social model of disability means to me.”

I’ve read a number of these student pieces.  They are insightful and compassionate, yet so far all have been convergent, suggesting that we may have unwittingly created a mini-echo chamber.  Ultimately I hope to find examples of divergent as well as convergent student thinking.  And if I don’t, then I’ll know we need to fail better next year.  If people come to discussions feeling compelled to converge and conform, then we have undermined the probing so vital for health equity progress.

Let’s apply this thinking to the recent Association of American Medical Colleges’ report, Advancing Health Equity: A Guide to Language, Narrative and Concepts, a provocative blend of critical theory and therapeutic diversity.  What should we do with it?  We should use it as an important basis for constructive conversations about increasing health equity.  But I’ll tell you what we should not do with it.  Treat the report as revealed truth, something that we uncritically and mechanically ingest and impose on our students.   

In discussing the report, we need to avoid applying a dualistic good-bad framework.  The most toxic words for already-difficult discussions are these: we need to see both sides of the issue.  No we don’t.  We should reject seeing both sides of an issue, because few issues have two and only two sides.

Both sides framing invites polarization.  John Dewey called these “pernicious dualisms.”  Instead pursue a multiplicity of perspectives.  If your discussion is trending toward both sides polarization, tease out a third or fourth perspective.  By embracing multiple perspectives, you undermine dualistic conversational polarization.   

So here’s my tentative plan for addressing this valuable report in our medical school.  I base it on one important concept: there is difference between taking a problem seriously and taking a solution seriously.   In small groups, apply multiple perspective thinking by addressing individual elements of the report in two steps.

First, does this element identify a real health equity problem?  This may be an entire section of the report, such as the one about competing narratives.  Or it may be a specific proposal for alternative language use.

If you conclude that the identified problem is irrelevant to health equity, move on to something else.  However, if you agree that it is a real health equity problem, then address question two: how good is the proposed alternative strategy, why, and what additional strategies should you consider?

Drawing on the multiple perspectives of discussion participants, maybe you can come up with better ideas, for example more effective narratives or more user-friendly alternative language.  In this way you can ground health equity discussions by connecting the micro-examination of language with macro-focusing on its role in the pursuit of health equity.

This brings us to the A in HEAL: Assess.  Continuously assess yourself.  You can’t fail better at health equity conversations without continuous self-reassessment.  Reconsider your personal beliefs about various aspects of diversity.  Ways you might address health equity issues or respond to diversity-related questions in the classroom or in clinical settings.  Maybe most important, your use of diversity language.  The key point: decide in advance what language you will use and clarify the rationale behind these choices so that you can quickly and effectively explain it, if necessary.  That will greatly simplify your discursive life.     

Let’s start with one basic principle.  Try to avoid wrong words, but don’t obsess about finding right words.  They usually don’t exist.  Both wrong and right words are moving targets.

In diversityworld, right is not the opposite of wrong.  The opposite of wrong is preferred, and preferences change.  So language reassessment must be an ongoing process, not the pursuit of eternally correct language.  Fail better.

Of course we should avoid obviously wrong words, such as historically-grounded negative group epithets.  Obviously.  But once you pass “obviously,” things become more complicated.  Wrongness is not fixed.  It is transitory.  Not long ago you could insult people by referring to them as queer.  Now the word has evolved into a source of LGBTQ pride.

Then how about ascertaining right words?  For twenty-five years I taught at the Summer Institute for Intercultural Communication.  Small, intensive, week-long classes for diversity professionals.

In one of my classes there was only one student who shared my ethnic background.  A participant asked, “What is the correct word for (pause, implying ‘my people’)?”  I nodded my head, deferring to the other “my people.”  She also nodded, deferring to me.  Then we both spoke up, simultaneously.  She said “Hispanic.”  I said “Latino.”  We both burst out laughing, because there is no right word for “my people.”

So how do you decide what to call an ethnic group?  Through continuous reassessment.  I use three admittedly imperfect indicators: surveys of how groups self-identify; the way ethnic organizations label themselves and communicate; and observing how members of a group talk.

According to the most recent self-identification surveys of “my people,” some 45 percent prefer Hispanic and some 25 percent prefer Latino.  So, although I prefer Latino, in conversations I alternate Latino and Hispanic when discussing the group.  Latinx?  Never.  Why?  Because I follow the principle of respecting group self-determination.  These surveys report that fewer than 4 percent of all Latinos prefer Latinx.  For any group, until a term achieves a high level of in-group support, I will not use it as a group label.   However, I respect how individuals self identify.    

What about the future?  Who knows?  The greatest support for Latinx comes from young people in the arts or higher education, particularly on the west and east coasts.  In contrast, two major national Latino organizations recently announced that, because of opposition within their membership, they will no longer use Latinx in their communications.

What about listening to others?  For decades I have primarily used Native American, occasionally Indian.  But I was reassessing: maybe I should stop using Indian.  Then I attended a recent zoom conference featuring Native American speakers.  On a whim I decided to keep a tally of group self-references.  Much to my surprise, they used Indian more than two thirds of the time.  Hit the pause button on reassessment.

I alternate African American and Black, but I still use Negro in its proper historical context, such as when referring to the United Negro College Fund or the American Negro Theater, which birthed such luminaries as Sidney Poitier and Harry Belafonte.

I try to use each person’s preferred pronouns, although my 87-year-old brain doesn’t always cooperate.  And I have little compassion for professors who hide behind academic freedom when refusing to recognize an individual’s gender identity.

I’m a grammar curmudgeon who at first refused to use they as a singular pronoun.  But in one of my recent public presentations I quoted a Chinese immigrant and needed to use a pronoun.  So I asked a Chinese Singaporean colleague if the name was masculine or feminine.  He replied that it was a unisex name, like one of my daughters.  He suggested that I use they.  I did and it felt natural, certainly much better than the laborious “he or she” or, even worse, some artificial “she/he” compound.

Diversity does not stand still.  That’s why we need to continuously reassess the way we think, talk, and teach about such themes as privilege, inequities, bias, or trigger warnings.

Take microaggressions, which I often address in my diversity workshops.  Derald Wing Sue’s widely-cited book, Microaggressions in Everyday Life, which I admire, includes an influential list of microaggressions.  It’s a list we should reflect on and discuss, but not bow down to or rigidly impose on others.  Unfortunately, some of Sue’s disciples have done just that.

Take the first statement on Sue’s list: asking someone “Where are you from?”  I often ask that question.  So why is it on Sue’s microaggression list?

Because some people refuse to accept the response and add, “But where are you really from?”  This follow-up question, which implies that the respondent has been hiding her true identity, is bloody awful.  But the original question — “Where are you from?” — is perfectly fine.  It helps us establish connections and learn about each other.

Here’s the problem.  Instead of challenging the use of “where are you really from?,” some microaggression zealots advocate that you should never ask anyone where they’re from.  Throw out the bathwater.  And while we’re at it, let’s toss out the baby, too.   

We desperately need to re-orient our interpersonal relations around what Tish Harrison Warren has called the “quiet, daily practices that rebuild social trust.”  So by all means ask people where they’re from.  This helps to build connections.  Just don’t ask them where they’re really from.

This brings me to L, Lead.  All medical educators are role models.  In the pursuit of health equity, you need to lead by role modeling a willingness to deal openly with difficult ideas.  At times you may fail.  So be it.  Fail better next time.

So what should leaders of difficult conversations role model?  Three R’s.  Risk.  Restraint.  Resilience.

First, role model the taking of risks.  Let me share three brief stories of people who role modeled taking risks by speaking truth to power.  I was the power.

In one of my workshops I was talking about women’s suffrage and mentioned the word suffragette.  A participant corrected me, saying that the proper term was suffragist.  I thanked her, checked it out, and discovered she was right.  Suffragist has replaced suffragette in scholarly literature.  I now use that example to illustrate how someone’s risk-taking helped me reassess and learn.

One of our campus staff members asked me if we could meet.  Over lunch the staff member explained that he (or so I thought) identified as she and was now transitioning.  She shared with me perspectives that I sorely lacked and is now writing her doctoral dissertation on the transgender dilemma of being forcibly de-transitioned after death.

One of my former students, who is blind, pointed out to me that my disability language was out of date.  I had long observed the group label evolution from crippled to handicapped to disabled, even differently abled.  Then some disability support organizations came out against differently abled, calling it a “trendy euphemism” that obscured the real challenges they faced.  Now there are efforts to replace disabled with impaired.  Impairment communicates that there are continuing challenges, yet also expresses the capacity for fulfilled, productive lives as long as society makes adjustments to those impairments.

The second R, restraint.  These three young people role modeled leadership by taking the risk of offending me.  I’m better off because of their interventions.  However, notice what they did not do.  None of them asked me to apologize.  They simply wanted to help me learn.   

We make health equity conversations even more difficult if we turn them into gauntlets of apology demands.  Of course you should apologize if you say something egregious.  But not for every misstatement, every name mispronunciation, every incorrect gender pronoun.  Over-apologizing can turn into a verbally destructive spiral with demands, apologies, then demands for better apologies, then apologies for inadequate apologies.  Stop!    

These three young people did not call me out.  They called me in.  We need to make more people welcome in our difficult health equity conversations, not use those conversations for public shaming.  Show restraint.  Health equity advocates should call people in, not call them out.

Third, resilience.  Let me add a fourth young person to my cadre of leadership role models.  One of our first-year students recently contacted me and said he wanted to take me up on my challenge to create “safe spaces for unsafe ideas.”  He wants to bring students together to share the experience of talking about challenging ideas.  They’ll probably make mistakes, but I hope they’ll learn to fail better.  That’s how you develop personal resilience.

We need to create robust, risk-taking conversations about health equity and stop focusing on verbal mistakes.  So I’m reassessing the very idea of safe spaces.  My conclusion: I think I’m going to stop using that term, for two reasons.

First, the idea of safe spaces deludes people.  There is nothing we can do to guarantee that conversations will be risk free.  So let’s stop promising safety, since we can’t deliver on that promise.

Second, in the pursuit of the safe spaces illusion, teachers and facilitators sometimes list discussion rules focused on mistake avoidance.  This strategy is probably harmful to the cause of health equity.  Why?  Because in trying to sanitize conversations, such a listing contributes to greater silence by sowing seeds of distrust.  The result: faculty, staff, and even students who refrain from discussing these important issues in order to avoid the risk of errors.  Rules do not guarantee safe spaces, but they increase the likelihood of sterile spaces.

Of course there may be special circumstances where it is necessary to establish conversational guidelines.  But don’t make mistake-avoidance discussion rules your default position.  Try operating on the intercultural principle of building mutual trust.  I’ve been doing that for fifty years and have seldom been disappointed.

With this in mind, I’m considering changing our health equity curricular motto from “safe spaces for unsafe ideas” to something else.  Not sure exactly what.  Maybe something like “robust conversations for effective change.”  I’m still reassessing.

So let me conclude by summarizing my HEAL suggestions for leading and participating in difficult yet productive health equity conversations.  In reverse order.

***To empower others, role model leadership by publicly demonstrating your willingness to take risks, show restraint, and be resilient as you strive to fail better.

***Continuously assess and reassess your diversity thinking and language, while developing clear, explicable rationales for your decisions.

***Embrace divergent thinking by listening carefully and reflecting thoughtfully about others’ ideas even if they challenge your beliefs.

***Finally, help marginalized communities by avoiding bridges to nowhere and by keeping conversations focused on our ultimate goal, the pursuit of health equity.

Dr. Carlos E. Cortés

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