Transcript has been lightly edited for clarity and readability.

Kerry Whittemore: Welcome to the second in the two-part series with Dr. José Rodríguez. Our last episode ended with Dr. Rodríguez discussing how diversity and inclusion is accounted for in the accreditation process. We will pick up right where we left off. Enjoy. 

KW: How would you define your role as Associate Vice President for Health Equity, Diversity and Inclusion?  

José Rodríguez: Great point. I feel like my job is to help create the structures, policies, and accountability mechanisms to create change. When I say structures, let's talk about positions. We have a medical school that has an Associate Dean for Health Equity, Diversity and Inclusion. Okay, that's great. That's one person. We need more. But that person now has an Assistant Dean for Health Equity, Diversity and Inclusion, but they also need more staff members to work in that office. And so that's a structural thing that's just about getting your hands dirty in the work. 

On the other level, that highest executive level of decision-making at the School of Medicine, needs to have the diversity deans at that table. That hasn't happened yet. However, there are changes that are afoot and so the decision-making body of the School of Medicine is called the School of Medicine Executive Committee. That body has all of the Chairs and some of the Associate Vice Presidents, and some of the Chief Financial Officers, Chief Marketing Officers, those kind of things. 

KW: Are you on that?  

JR: Yes. I'm not a voting member, but I'm on it, which is an interesting phenomenon. At the medical school education level, where Dr. Samuelson really is in charge of that, both of the diversity deans are on that decision-making body. So that's the structural changes that we have to have. When it comes to health sciences, there's a School of Medicine, which is by far, the largest faculty, but really the MD program is fairly small, with 500 students. Let's say by some miracle, we get to 200 students a year. Great, that makes it 800 students. The College of Health has 5000 students. And so that's part of the AVP's role as well, is to make sure that the equity, diversity, inclusion efforts that are going on at the health system level are actually happening at all of the schools, not just the MD program or the programs that are not the MD program, at the School of Medicine. 

We provide supervisory support to the Health Equity, Diversity and Inclusion office at the School of Medicine, who I must say, are doing a bang-up job, because the work that they have to do is, right now, essentially beyond what their FTE allows, and they're still doing it. 

KW: I went to medical school in Montreal, Canada, and I don't remember my medical school classes being very diverse, even though the city of Montreal is quite diverse. Is this mainly a US issue or, if you look internationally, are we worse or better than in Europe or Canada? Do you know that, by any chance?  

How does the United States compare to other countries in medical school diversity?

JR: What a great question. The United States has been talking about having more diversity in medical school for some time, and they've been working on it, but I'll say that in other countries, like Ecuador for example, there are six private medical schools, and those six private medical schools charge tuition that looks just like what the University of Utah charges for out of state, in a place where the monthly minimum wage is $400 a month. So for the most part, the medical schools are only for the wealthy. However, the public schools also have medical schools, and those are for people who can get in by passing the test. And so, if you come from a family that has enough wealth for you not to be working in school, then of course, your chances of getting into those public medical schools are much better, and it turns out that they are far more competitive to get into the public medical schools, than the private ones, because the public ones are free. 

Essentially, what you end up with in Ecuador, is a high concentration of people from the same classes that Abraham Flexner recommend that we select from. And this happens in other places as well, even in places where the majority of the students are black. Think about places like Haiti, think about places like Nigeria, same exact thing. 

KW: In terms of the socio-economic background of the students?  

JR: We really do select from the highest echelons of society, everywhere in the world. I think it might be a little different in Europe now, only because of how they pay for medicine, because when you graduate as a family doc, you make 1500 euros a month, which doesn't sound like a lot of money to me. And that's different. 

KW: One other thing I think about diversity, like I said before, is gender. Slightly more than half of all medical students are female, and I think 2019 was the year that that switched, although it had been pushing at 50% for a while. Yet, the professor track—for those of you that don't know—in academic medicine and academics in general, it goes from instructor to assistant professor, to associate professor to full professor being the highest. If you're, like yourself, Dr. Rodríguez, a professor of medicine. In the United States, 66% of full professors are male, while 34% are female, and I feel like it should be better, with the number of years that there's been a lot of females in medicine. 

JR: Well, women in medicine, even like I said, half of my class, we're talking 30 years ago, were women. And you might know Dr. Hobson-Rohrer, we went to school together. She was a fourth year when I was a first year. Her class was half women. So we've had the ability to change this for decades. 

KW: Right, that's what I'm saying. It's not like a new thing. 

JR: No, it's not. 

KW: That's equally depressing. 

JR: Well, and I think you're kind, when you say it's depressing. What it is, is unconscionable, there is no excuse for it. And think about the fields that both of us are in. You're in pediatrics, I'm in family medicine, both of them are majority women fields and have been for decades. Yet, if you look at leadership in those fields, there are still the great majority of the chairs are men. I think we talk a good game, but I think we have to do some kind of hard decisions. It has to do with privilege. I'm male, that's my identification; that imbues me with privilege. My job, with having that privilege, is to actually change it so that people who are not male, have the same privilege. Sometimes, that's easy and sometimes that's hard. The other day, I was invited to do an editorial for the Journal of Women's Health, which I thought was fabulous. 

KW: And then you realized you're not a woman, maybe a woman should write this. 

JR: I said, "Oh, we should definitely have the women who I work with in my faculty development course, write this." And so they did. That's what it is, it's about giving privilege. They wrote a fabulous article about abolishing the minority women tax, because I think that it's important to talk about women, but we have to make sure that when we talk about women that it's an inclusive term, because I think that Black women are left out of that conversation, and Latinas are, as well. How do we make that more inclusive and make that something that we actually work to change? That's my job. My job is a change agent, my job is to make room, my job is to make space. My job is also to talk for the people who aren't in the room, and not to say, "Oh, I'm going to talk for all Black people because there's no Black people here," but to say, "I recognize that there are no Black people here, so we need to have people in this conversation." And then to say, "And look forward." 

KW: I even feel like I do that with mine, since you said I'm a pediatrician and as you know our clinic is really diverse, I have these female high school students whose families are from Somalia or Iraq, and I was like, "What do you want to do when you grow up?" Like "Become a doctor." "You should take my job. And we need people that look like you, who come from your background, to take care of folks." I feel bad that in our office, other than the Spanish clinic, everyone's pretty much white, almost taking care of all of our patients of color. I wish it weren't quite that way. 

JR: But thank goodness you're there, and I'm grateful for you, because it's not so much that you have to be from the same ethnic group as your patient, although that helps. It is that you got to have the right attitude and be able to go the extra mile, and that's what you do. I don't want to minimize your contribution here. The other day, a paper came out, just saying that how Black women who have Black doctors taking care of them during their pregnancy, the infant mortality rate goes down by 50%. 

KW: I saw that.  

JR: Isn't that an unbelievable thing?  

KW: Yes. 

JR: Now, all they looked at was race and ethnicity. But it also comes down to some other things. When I think about the kind of work that I do, I got to be able to sit in a room and be able to look at that patient and say, "My goodness, you could be my grandmother." Okay. That changes how I act, what I do and how I think. This is the kind of thing that a lot of our providers do at Redwood. But it's learned behavior for a lot of people, and so I think, once it becomes automatic behavior, it'll be better. But the imperative right now is to get more people who look like our patients, especially our Somali patients. Good heavens, what would it be like, to have a Somali provider working with us? Oh my gosh. 

KW: That'd be amazing. 

JR: It would change how we did our job. 

KW: For sure. A lot of the things we've talked about are fairly depressing and kind of negative. Are there any positives that you see, or things that you see changing? Even your position, did your position exist before you?  

What are the positive changes you see happening in the medical field?

JR: My position is pretty old. In fact, more than 15 years old, and I have this whole list of predecessors in this position. The most recent one was Dr. Ana Maria Lopez, who left in 2018. But before that, it was Dr. Evelyn Gopez. And before that, it was Dr. Junkins and Dr. Davis (I don't know their first names). There's a whole list of them. One of the things that was happening before is that, there was an Associate Vice President office, a School of Medicine office, and those two weren't on the same page. So that's the other job, is coordinating this effort and making sure that we can do it both at the School of Medicine and at the other schools. For the first time, the College of Nursing is recruiting for an Associate Dean of Equity Diversity and Inclusion, the College of Health is doing the same thing. The School of Dentistry has somebody with that assignment, but I think we're going to have to get somebody who has that title. Then the only one that's left is the College of Pharmacy. 

Once we have deans doing that, it ensures that we have a voice at the highest levels of college leadership, to advance the ideas, principles and the science of diversity, because it is science. It's not just looking at numbers and saying, "Let's make it look like the population." Boy, that would be easy, because if we have four Black students and we only have 1% of the state is Black people, then we're done. That's not how it works. We pull from a national pool, we got to look like the applicants, not just our state. And the applicant pool is much higher than 1% or the 4% that we have now. And so we'll see how this goes.

I'm optimistic because of three things:

1. There's consciousness about equity, diversity and inclusion. EDI is no longer seen as the exclusive purview of people of color. I'll tell you that two years ago, I really felt like people thought I was the only one who had to do this job. So things are changing rapidly there, so that's a cause for optimism. 
    
2. We have leadership that are willing to pay the political price to make things happen differently. One of them is to have that Assistant Dean in the School of Medicine, the other one is to have these other deans at the College of Health and the College of Nursing. There's also going to be an assistant vice president who's going to be a senior director in my office, who's going to be a faculty member, that one is already out. We've also recruited a Senior Director for Equity Diversity and Inclusion at the hospital. Now, that's a huge, huge deal, when you think about the hospital has almost 14,000 employees, and it has the highest number of Black and Latinx employees of any unit in probably the State. Alright. That person is going to sit in the Ops Council, at the hospital. So that's going to be different.
   
   In health sciences, again, the people that are getting named to these positions are going to be sitting, some of them will sit with me. I can't be everywhere, but when I go to meetings, the senior director will go with me, because there's another principle here, and that is if it is only one voice, that ends up to be tokenizing, and it hurts. So what we need to do is to create opportunities for multiple voices. And until now, there's the political will to make it happen. If we look at the School of Medicine, for example, we have 22 chairs, and many of them have already named vice chairs for Equity Diversity and Inclusion, and those vice chairs will work with Dr. Kemeyou, who is the Assistant Dean for faculty equity, diversity, and with my office and with Dr. Cariello, to actually implement this work at the department level. Some departments have vice chairs, my department has named two associate chairs. 
    
3. There's a lot of people in the university, working on it, but the way we're working on it is different than before. Before, I think we were just trying to do the work. Now, what we're doing is, trying to help the people who are in charge of this do the work. So I'm not a residency program director, but Dr. Kemeyou and Dr. Cariello can work with the residency program directors, to ensure that the things that need to happen to increase the diversity of their residency class, happen. One of the things we learned, here's an easy thing, and I could talk to you forever, Dr. Whittemore, is that every residency program interviews 10 people for every seat. So family medicine interviews 100 people for 10 seats, internal medicine interviews almost 400 people for 40 seats, pediatrics is the same way. Ophthalmology interviews 40 people for four seats, dermatology interviews 40 people. Alright. So the issue is, if you want to increase your diversity in the residencies, you need to do the same thing for that underrepresented medicine category. So if you want to be able to recruit one underrepresented in medicine resident, you need to interview 10. If you want to recruit four, then you got to interview 40. And that knowledge is new knowledge. We didn't know this until this year. 

KW: Yeah, I hadn't heard that. That's news to me. But it is interesting, most people end up practicing where they do their residency, have faculty be diverse. It's good to have residents who are diverse and then medical students and down the line. 

JR: Yeah. So we're working on it at all fronts and we're seeing change. In transformation in the dermatology program, a program that hadn't had a single resident of color three years ago, and now has, I think, two Black residents and a LatinX resident. So it's 30%. Four years ago... 

KW: Dermatology is a whole other subject to talk about, and the fact that all my dermatology books are filled with white people, with their rashes. [chuckle] 

JR: Yeah. Well, [chuckle] there is that. And I think you should know that the dermatology department has been working with the curriculum committee to change all the slide sets for dermatology, that are presented to the med students, to have representation for multiple skin tones. 

KW: Yeah, because it does sometimes make it challenging, even as a physician, when I'm seeing patients of different skin tones to say, "Well, I don't know what exactly looks like here." Lastly, I liked the quote that you have at the bottom of your email, so I wanted to say it and see where it's from, if you made it up. "Nothing about us without us." Where does that come from?  

JR: So I saw somebody have it as their Zoom background. 

KW: Oh, really? [laughter] 

JR: Oh my gosh, I got to look this up. It's an old Latin saying, that comes from the Roman Empire, not known for their inclusivity or their kindness or anything. And no offense to those of us who might be related to the Romans, but still, they weren't good people. But that's what it comes back to, and the way the full quote that I saw was, "Nothing about us without us, is for us." Now, I like that "Is for us" stuff as well, but I didn't feel like making people pissed off. If you talk about me without me being in the room, then you're a bad person. So I think that what it means is that, if we're going to be making decisions for this diverse population that we serve, we need to have representation from it. That's just how it is. And that representation has to come either through the faculty line, through the patient line, through the staff line, but we need to do it, because if it's about us without us, it really isn't for us. 

There are things that communities need, that I don't know. I don't speak Somali, and there are things that they need, that I don't know about well enough to talk intelligently. But I do know people who are from that community who can do it. How do I get their voice in front of the people who make decisions? And that's where our job is. 

KW: Anything else that you think I should know? I know you could talk about this for hours. 

Parting thoughts?

JR: Well, I think that we should look at what we're doing and be happy that we're changing so quickly. So the second year class of medical students has six LatinX students, and the first year class has nine. That's a third more. That's a huge amount. The second year class had one Black student, now there's three. That's a 300% increase. That's the clear evidence that we're moving in the right direction, and we need to continue moving in that right direction, and I think that there's actually appetite for it. Our offices are designed not to do this work exclusively, but to work with all the other offices, which I think is a great example of a place where we can have collaboration and cross-pollination, to make sure that we're doing the work together, because having it reside in one place is good for coordination, but it is not good for getting the work done. It has to exist in all of our psyches, and I think it does exist in a lot of our psyches, and I think people are willing to pay the capital to actually make it happen. I'm actually optimistic about what we're going to see in residencies. I think it's going to be very different this year. 

KW: Is there anything you can point to that's responsible for the increase in those numbers over these last couple of years of the medical students?  

JR: Oh, I think it's intentional. I think it's Dr. Chan and his team who've seen this is an area of improvement. 

KW: The holistic review process?  

JR: I think holistic review process is part of it. I think there is some money, I don't think there's a lot of money there. I think once there's money, that could change drastically. I think that the biggest thing is that, we are actually interested in recruiting for diversity, instead of looking for the reasons why. So there's two ways to do this. We could recruit for diversity, or we could explain why we don't have it, and I think what has happened is a general recognition, is that a class that is not diverse is bad for all of the members of that class. 

KW: And for the patients that they'll be taking care of in the field. 

JR: Yes, I learned more about taking care of Puerto Rican patients from my Puerto Rican roommate in New York City in med school, than from anybody else. You think about that. This is who I grew up around, and yet, the places I learned was from my colleagues. The same is true for Black students, for Black patients. That's what we need to provide for our students. They'll learn more from each other than we can ever teach them. That's why we have to figure out who the "Each others" are. And I think, I really do feel like Dr. Chan and his team have done a great job, and I think they've recognized that there is a ton more that has to happen. We're ready to work together. And that gives me hope. 

KW: As always, please visit our website to find information on obtaining CME credit for listening to the podcast, as well as to find pertinent journal articles on the topics discussed. Thanks.