Hello and welcome to the Latinx Emphasiatry and African American Community Session entitled Critical Conversations, Recognizing and Mitigating Workplace Bullying. Good afternoon, buenas tardes, welcome, bienvenidos. So this is our first community session in which we include a lecture. This community session is sponsored by both the Latinx Emphasiatry and the African American Emphasiatry groups or communities. I am Glenda Lizbosquez, I am the chair of the community and I'm being joined by Karin Velez, who is the vice chair, the new vice chair of the community for this year, for the next term. Personally, I'm currently at Dell Med, I'm the chief of Peds PM&R in Dell Medical School with UT Austin, I'm the chief of Peds PM&R with Dell Medical, Dell Children's in Austin. Karin, do you want to introduce yourselves and then introduce Dr. Powell? Sure. So, like Dr. Voskes mentioned, I'm Dr. Velez, I am a physician with dual board certification in spinal cord injury and PM&R. I am the newly appointed medical director of inpatient rehabilitation services at Advent Health Waterman in Central Florida. I have the pleasure of introducing one of my diversity and inclusion committee colleagues and moderator for this session for the panelist discussion, Dr. Danielle Powell. Good evening, everyone. My name is Dr. Danielle Powell and I have the honor of serving as the moderator for tonight's session. I currently work at the University of Alabama at Birmingham and serve as the interim chair, as well as the associate, as well as an associate professor. Clinically, I am also the medical director of our multidisciplinary spina bifida program. We can move to our next slide. And I also have the pleasure of introducing our faculty panelists. So we will start with Dr. Al-Awadi. Thank you, Dr. Powell. So my name is Dr. Al-Awadi. I'm a physical medicine and rehab specialist, board certified in Canada and the US, as well as brain injury subspecialist. I am practicing currently at Texas Tech University Health Sciences Center, El Paso. I'm the only physiatrist there, so I'm doing the full meal deal. I have the honor to introduce my colleague, Dr. Cruz Jimenez, and I'll leave the podium for her. Good afternoon, everybody. I'm Dr. Maricarmen Cruz. I'm a board certified physiatrist, active practice, and I have dedicated my whole career to academic medicine. I'm the associate chief of staff for education at the VA hospital in Puerto Rico, San Juan VA hospital. And I've been in that role, I have been overseeing all graduate medical programs, including internal medicine, psychiatry, and physiatry, and internal medicine subspecialty. So I've been involved in GME, and this topic is very dear to me because of the role it has in respect to dynamics that we see in the workplace. So it's a pleasure to be here tonight, and I would like to ask Dr. Salvador Portoel to introduce himself. Hi, I'm Salvador Portoel, I'm an interventional spine and sports medicine physiatrist here at NYU. I am the medical director of sports medicine rehabilitation, and fellowship director of the sports medicine fellowship program here. And next, Dr. Williams. Hello, and good evening everyone, I'm Dr. Coriander Williams, I'm a board certified physiatrist currently serving in the Houston, Texas area. This is also an area near and dear to my heart, so I look forward to discussing this further. And before we continue with the presentation, I just want to plug in our Latinx and physiatry community, and the African American physiatry community. So if you have not joined our phys forum community, or some of the other social media presence and other platforms, please look for us, reach out to us, we would love to continue building this community together. Thank you. So we have, our faculty have no relevant financial disclosures related to this activity. Also Dr. Velez is an advisory board member for the National Workplace Bullying Coalition, and an affiliate of the Workplace Bullying Institute. So now I will turn it over to Dr. Velez, who will go over the objectives for our presentation. Thank you, Dr. Powell. So at the end of this activity, you will be able to define workplace bullying, describe the impact of workplace bullying, both on targets and organizations, and we will outline strategies to mitigate workplace bullying, both for targets and organizations. So as a member of the Diversity and Inclusion Committee, I've learned that it is important to have difficult conversations. It might be challenging, yet it'll help us gain a better understanding of other people's perspectives. One of the topics that can be considered a difficult conversation is workplace bullying. Did you guys know that healthcare and education are the prime industries that are most exposed to bullying? Not only can it affect the healthcare worker satisfaction and overall well-being, it can also create a hostile work environment that ultimately affects patient care. It tends to be underreported for two main reasons. One, avoidance of conflict, and then the second one for fear of retribution of those that are affected. So the main goal of the lecture is to become familiar with what constitutes workplace bullying and learn strategies to mitigate its harming effect, both on individuals and on healthcare organizations. In order to do so, we're going to discuss workplace bullying definitions and similar terms, some of the bullying tactics and types of bullies. The prevalence by gender, race, and industry. How to measure workplace bullying. The effects of workplace bullying on targets and organization. And we'll also discuss a little bit about microaggressions. Then I'm going to pass the podium to Dr. Powell to do a panel discussion on mitigating strategies for targets and organizations. The Workplace Bullying Institute defines workplace bullying as a repeated harmful mistreatment of an employee by one or more employees. It can be abusive conduct that manifests itself as verbal abuse, physical and nonverbal behaviors that are threatening, intimidating, or humiliating, work interference or sabotage, or a combination of some of the above. Please note that this misconduct is unwelcome and unwanted by the targets, and it tends to be a pattern of repeated behavior over time, not just one incident. The harm or injury to the targets tends to be exacerbated by exposure time to the abusive conduct, and the goal of the perpetrator is to distress or control the targets. The National Workplace Bullying defines it as unwanted abuse of any source of power that has the effect or the intent to intimidate, control, or otherwise strip a target of his or her right to esteem, growth, dignity, voice, or other human rights in the workplace. These are behaviors that can take the form of interpersonal interactions, organizational practices, or management actions. It can occur face-to-face or via cyberbullying, and it can also occur at any level of an organization, so either via supervision, among co-workers, or other third parties. Similar terms that have been described in the literature include incivility, abusive conduct, psychological violence, lateral and horizontal violence tends to be used in the nursing literature, mobbing, disruptive behaviors, workplace aggression, and workplace violence. Of interest is the term disruptive behavior because this is the preferred term used by the Joint Commission, and they define it as behaviors such as physical aggression, verbal abuse, bullying, publicly humiliating others, and inappropriate discontinuation of communication that destabilizes psychological safety and the well-being of team members. It's measured using a disruptive behavior scale, which I included in the slide. The responses are collected using a five-point Likert scale that ranges from strongly disagree to strongly agree. So now I want to show a video of a typical workplace bully. And, well, I would appreciate it if you didn't yell at me in front of the entire office. Excuse me, what? Uh, the yelling. Oh, you disapprove. I'm sorry. Did I, did I hurt your feelings? No, no, no. I just don't feel that it's necessary. Well, it certainly doesn't help me, and I think that there are... Well, I'm glad you brought this up. Great. Because I found that an office can't run properly if the lines of communication aren't open. Right, right, yes. So in that case, let's make a few things clear. Okay, great, great. No, this, this is helpful. I mean, let's review. What did I tell you the first day? Your thoughts are nothing. You are nothing. And yet you have the nerve to walk into my office and tell me that... I, I... Please shut up. At least allow me the courtesy of finishing what I have to say. That's the very least that you can do after I've had to endure your insults. This is a bad time. Who do you think you are, you snot-faced little punk? Let me make this clear for you, okay? And now try to follow me, because I'm going to be moving in a kind of circular motion. So if you pay attention, there will be a point. You are nothing. If you were in my toilet bowl, I wouldn't bother flushing it. My bath mat means more to me than you. You see this? This means more to the office than you. And yet, do you hear any complaints when I do this? These pencils more important. These pens more important. These paperclips more important. You miserable little crybaby. You don't like it here, leave. There are thousands of people who would kill for your spot. Who would kill for the opportunity to be here. I could spit and hit somebody who could do this job better than you. This is the fast track to the top, boy. I don't see you breaking any speed records. Why can't you show a little backbone, huh? Huh? I don't think the yelling is necessary. Gotta be a little more thick-skinned, you turd. I commanded you to stop! So that was a little extreme case, but just a sample that came from the movie Swimming with Sharks, which was aired in 1994. So the literature does describe, or Drs. Ruth and Gary and Amy in the book, The Bully at Work, describe four types of bullies. So the first one is the screaming mini. These people can choose public settings to showcase attacks. They control via fear and intimidation, and they satisfy their need to control, dictating the emotional climate in front of audiences that are supposed to tremble as a result of their behavior. Another type of bully would be the constant critic. Contrary to the screaming mini that does it in public, these operate behind closed doors so that later he or she can deny what was said or done to you. They aim to destroy your confidence in your competence, and they satisfy the need to control by obsessing over others' performances. We also have the two-headed snake, which pretends to be nice in front of you while sabotaging you behind your back. Their friendliness only serves to decrease resistance to giving information that may later be used against you, and they satisfy their need to control by managing the image of the target in other people's minds. Last one is the gatekeeper. They tend to be the right hand of bosses or supervisors or managers, so they need to establish themselves as one-up to you in order to order you around or control your circumstances, and they satisfy their need to control by putting themselves in the middle of everything, making them feel important. Interpersonal tactics that bullies use will be disrespectful or destructive interpersonal conflicts like the screaming mini and just like the example we saw in the video, emotional volatility of the perpetrator. They might use verbal and nonverbal behaviors in order to criticize and humiliate and shame their targets. They also do what's called character assassination or just to tarnish your reputation within the organization. They might exploit the targets via managerial prerogative. They do work interference, which ends preventing the target from performing their daily duties, and a form of organizational bullying would be ostracism or social exclusion. An example of this would be if a manager tells other employees, don't interact with this person because this person is a troublemaker and you don't want to affiliate or associate or be thought of as a troublemaker. That way, that person, it's socially excluding them either from meetings or from any other type of social activities. So in terms of prevalence, the Workplace Bullying Institute published a survey in 2021. They've had other surveys and the last one previous to this was 2017. They asked the following question, at work, what has been your personal experience with the following type of repeated mistreatment? Abusive conduct that is threatening, intimidating, humiliating, work sabotage, or verbal abuse. The results show that 13% are currently experiencing workplace bullying and 17% have experienced it in the past. So it's a total of 30% that have experienced it. There's 19% that have witnessed workplace bullying. And interesting is that there's 23% that are aware that workplace bullying exists, but have not had an experience and 34% don't even know what workplace bullying is or known that this is a phenomenon that occurs. If we take the information that we have previously, we mentioned that you can either experience or witness workplace bullying. Those two populations can be affected by workplace bullying. If you see that this is occurring, it can still affect you and affect your performance. So when we look at that, we see that 48.6 million workers have experienced workplace bullying, 30.6 million have witnessed workplace bullying, but it affects a total of 79.3 million of US workers, which will be the equivalent of the combined populations of the 12 states that are highlighted in orange. When we look at workplace bullying by gender, we see that most commonly males tend to be bullies by 67% versus females. Then male bullies tend to target other males by 58% versus 42% of females. Females tend to target other females, 65% versus 35% of male targets. When we look by race and ethnicity, we want to look at these groups and looking at the columns, the light blue is the people that have been targets of bullying, and the darker blue is the people that have witnessed workplace bullying. So we see that the Hispanic population tends to be the most common group that has experienced workplace bullying. I thought it was interesting because the survey from 2017 had African-Americans as the second group most commonly affected, and then for this year, it changed between white and African-American. The last column for our Asian colleagues, the interesting fact here is that there's only 12% that have experienced or self-reported experience workplace bullying, but out of all the four groups, they're the ones that have witnesses the most. So this could be a bias to reporting because of avoidance of conflict and fear of retribution. When we look by industry, like I mentioned in the introduction, healthcare is the most common industry affected with a 27% versus 23% in education. Target licenses and professional certificates also show that registered nurses are the most common group targeted, followed by teachers with an 8%. So now we're going to go into some poll questions. You're going to rate the frequency with which you experienced the presented interactions with the following, one point for never, two for occasionally, three for monthly, four for weekly, and five for daily. The first poll question reads, someone withholding information that affects your performance. Never, occasionally, monthly, weekly, or daily. Let's see if we can get the results. There we go. So the most popular answer was occasionally with a 57%, monthly a 29%, and weekly a 14%. The next question reads as follows, having insulting or offensive remarks about your person, attitudes, or private life. Let's see if we can get the results for those. Again, the most common, we have a 13% never and followed by occasionally, which was the majority of the audience. The next question says being ignored or facing a hostile reaction when you approach. Never occasionally, monthly, weekly, or daily. And let's see if we can get some results. Occasionally continues to be the most common. Followed everything's 10% with never monthly, weekly, and daily. And the last one, persistent criticism of your work and effort. And let's see if we can get some results. Perfect. 50% occasionally. We have a 20% never and monthly, 10% weekly. And thankfully, no one has a daily experience. So can workplace bullying be measured? The answer is yes. So there's a couple of ways of measuring it. In 2009, Einarsson et al developed the negative acts questionnaire. This was then revised in 2013 by also Einarsson and Nodelaers. So they have 22 items that they classified using a five-point Likert scale, similar to what the questions that you had on the poll. So from not at all, occasionally, monthly, weekly, and daily. In order to be considered a target of workplace bullying, you must endure negative acts at least once weekly for a minimum of six months. And then the cutoff points are a score of higher than 45, you would be considered a target of bullying. If you have less than 33 points, you are not bullied. And you can have occasional bullying if you have a score between 33 and 45. After they, in 2019, after they validated the revised questionnaire, they verified which one of the items have the highest specificity. And they narrowed it down to nine questions. And that's how they developed the short negative acts questionnaire. Same question, so it's just removing them from the original poll. Same conditions, negative acts, at least once weekly for six months. And the cutoff points here are targets of bullying, more than 22 points, not bullied if it's less than 15. And if you have a score between 15 to 22, you experience occasional bullying. Now I want to transition to the effects of workplace bullying on targets. So the bullying is going to serve as a stressor. That with frequency, it's going to cause distress within that target. If that target is experiencing significant distress for a long period of time, it's going to translate into stress-related illnesses. So for instance, if we look at the brain, with higher levels of cortisol, there's shortening of the dendrites. And that causes atrophy within the corticolimbic system. If it affects the hippocampus, you have difficulties with learning and memory. If the amygdala is affected, there can be emotional mobility and also difficulties with learning. And when it affects the prefrontal cortex, you'll have difficulties with motivation, with your affect, and with executive functioning. The effects of bullying can be physical, cognitive, and emotional. So for instance, one of the typical signs of workplace bullying or stress-related illnesses would be headaches, hypertension, which can go, which can happen silently and the person doesn't even notice, or insomnia. From a cognitive perspective, you can have poor concentration, a short attention span, and hypervigilance, among others. And then from an emotional perspective, you can have anxiety, depression, and mood swings. There are some people that can develop even what's considered a complex post-traumatic stress disorder. Thus, the targets of workplace bullying can also experience psychosocial effects. By being a target of bullying, you have a loss of your personal and professional identity. Why? Because as physicians, for example, if we go through this, we've put so much effort into becoming a physician that a lot of times our identity is linked to our profession. So by having damage to your reputation and feeling betrayed by those who you thought were your colleagues, that can be affected. You can also have a loss of workplace friendships and social networks, increased family problems because you're talking about the abuse on a regular basis and it affects your family, difficulties with reemployability, especially if the bullying ended up in termination. It can also affect your finances and you ultimately have a violation of your sense of justice and fairness. This slide is a negative conduct impact continuum. So on the left side, we have the milder forms of negative conduct and on the right side, we have the most aggressive or severe conduct. So for instance, we see if you experience impoliteness, incivility, or rudeness, that will be on the milder forms of negative conduct. This is then followed by microaggressions. We see that the onset of health impact occurs when there's personalized disrespect. Interesting that the authors of The Bully at Work and The Bully-Free Workplace, Drs. Ruth and Gary Namy, they mentioned that sexual harassment can be a little bit milder compared to workplace bullying, which initially when you hear that, it's like, what? What are you? The rationale was the following. Sexual harassment, when a target reports it, they usually are believed and there is an investigation following that because it is an illegal act. Bullying, on the other hand, although it is inappropriate, there is no law against bullying. Therefore, organizations don't have to investigate or follow through with those claims. And a lot of times, the targets of bullying are just simply not believed. Once the target is exposed to prolonged, frequent, severe, abusive incidents and there's no consequences to it, they can develop depression, anxiety, and even PTSD. We also see at the right side, they can even recur to self-harm or even suicide. Physical violence, injury, and death tends to occur if there's battery and pacing or if the target of workplace bullying is so distressed that they want to, quote unquote, fix the people that wronged them that they can commit homicide. The effects of workplace bullying is not limited just to targets. It can affect organizations as well. So it will be lower job satisfaction, there's less organizational commitment, work disengagement, which ultimately leads to lower productivity and performance. Your employees might have increased intentions to leave or just simply increased turnover. If the abuse is so severe and you're having physical symptoms, that'll lead to absenteeism. And if you're bullied because you take days off, it might lead to presentism. They can have harm to your organizational reputation and the creation of a toxic work environment and negative organizational culture. You'll have an ability to recruit and retain top talent. And there can be increased insurance claims and litigation. So bottom line, workplace bullying and mobbing is too costly for organizations to ignore. Now let's switch gears and move to microaggressions. The reason why I wanted to discuss this is that it's one of the milder forms of negative conduct. And with time, things could potentially escalate to bullying. So microaggressions are indirect expressions of prejudice that can contribute to the maintenance of existing power structures and can limit the hiring, promotion, and retention of underrepresented minorities. They come in three types, microinsults, microassaults, and microinvalidations. Microinsults tend to be unconscious and they're subtle. They convey a demeaning message to the recipient in a way that is unintentional by the perpetrator. It conveys rudeness and insensitivity and demeans a person's racial identity or heritage. Microassaults, on the other hand, are conscious in their intentional verbal and nonverbal attacks to offend the recipient. Microinvalidations would be unconsciously you're excluding, negating, or dismissing the personal thoughts, feeling, or experiential reality of a person. I'm going to leave you guys with this quote from the human rights activist, Janetta Sagan. Silence in the face of injustice is complicity with the oppressor. Now I'll pass the presentation along to my colleague, Dr. Powell, so that we can open the panel discussion. So the first question is, have you experienced workplace bullying at any point in your career? And if yes, how long did it take for you to realize that you were being targeted? So we're going to start with Dr. Boss. Thanks. Sometimes we're so tough on ourselves. So sometimes we minimize that it really is workplace bullying. So how long did it take for you to recognize that I was being targeted, maybe even after the fact, after it happened? So at least that's been some of my experience with the no sober stuff or stuff that we just want to excuse someone else for doing against us. Now I'll ask the same question to Dr. Al-Awadi. Sure. So I'm a fresh graduate. I literally finished my fellowship. But I can tell you that I have seen it during my training, especially with a two-faced person when they look nice and sugarcoating in front of you and stab you in the back. How long did it take me? It took me a while because you are being treated in a way and someone is presenting themselves in front of you in a way and talks about you in a different shape with other people. So it took a while to get and figure out that this person is a bully. And that required a fair amount of time to develop trust with other colleagues, with other health care professionals to know that it does exist. Yeah. And so it takes me a while. The main two reasons is it takes a while to figure that person. And maybe I'm a cheerleader kind of personality and give them the benefit of the doubt. But once you're sure about it, you're sure about it. Now I'll ask that same question to Dr. Cruz Jimenez. So yeah, I have experienced bullying at my career. And I would say that during training, particularly during my internship year in which you're getting education in a place that is not your home like PM&R, and then you start seeing the contrast of the way people are treating you. Probably takes a while because you consider that this is normal. At the moment, you consider that it's normal. It's part of the culture. But then it takes a while to realize that there is no reason. There is no justification for the way people treat you. So yeah, I would say that during training and during my professional years as well, I guess you just learn to recognize it easier and do something about it. But I would say it was more difficult to recognize that while I wasn't training. I'm probably more vulnerable, right? You're developing your character and deciding how you're going to use what you're experiencing and what's the way that you're going to react to it. All right, Dr. Portugal, same question. Unfortunately, I have experienced workplace bullying at a few different experiences. And actually, it was pretty immediate when workplace bullying was occurring. They were pretty aggressive in stating their case. And then it did take a little bit longer, maybe a few months, to realize that they were actually targeting me through other manipulative ways. And then Dr. Williams, same question. Unfortunately, I'm with my colleagues on this, and I have experienced it. And luckily, I actually have people who are around to help me realize what it was sooner than I may have realized myself. And so it was good to have at least some other evidence to have at least some other objective eyes to look in and say, that doesn't seem right. And it encouraged me to take a more objective look at things to see that things were correct. Our next question is, have you been the target of microaggressions in your career? How did you handle it? And we'll start again with Dr. Bosk. So for sure. I think their answer is going to be, for most of us, it's going to be yes, given the demographic in this group. I think how we handle it, or at least how I've handled it, it has depended on the level that I've been and the power that I have. So for example, during training, the only way to handle it at that moment sometimes was just to internalize and cope myself because of the feeling of powerlessness. As I've been able to get promoted and have like a position of leadership, I've been able and working on and reflecting on myself, on my own advocacy, on my assertiveness. I have been able to call it when it's happening. So basically, in summary, it has depended on how much power I have in the situation. OK, same question to Dr. Al-Awadi. Yeah, I have been through multiple microaggression scenarios, mainly the microinvalidation, probably because I might look younger than my age or minority. You kind of pick your battle. But again, trying to reflect on what happened with myself and what I should do in picking my battle is the main way to approach it. And hey, I have to, for me, for my satisfaction, I would document the situation or the experience. I would probably microanalyze it from my side before saying, yes, this was microaggression. Things should not have gone that way. And ask for help. I have colleagues around. And I'm like, this is what happened to me. What are your thoughts? So hearing different reflections from other colleagues who I trust. And then it depends on you hear different opinions. And you make your mind. And you move on whether you want to report it or you want to deal with it with that person one on one. So it really depends on how much you want to pick your battles. OK. Dr. Cruz, Jimenez, same question. I would say that I have experienced more microaggression than bullying throughout life. And I would say that I have seen the three discuss the insult, the assault, and the invalidation. Obviously, we're here because we're minorities. And we want to learn from each other some experiences that we have gone through. So I would say that being a minority in the federal government and trying to work with people who are from different cultures, you feel sometimes you feel people are looking at you and talking about you. And probably you go through that emotions. How I have dealt with that, I would say that I, myself, choose my battles too. But one of the things that I have gone through my career, one of the things that I do at the hospital is that I lead the leadership development programs in my facility. And that has taught me a lot about leadership, communication styles, and strategies to communicate values and the way I think. So I would say that another thing that I have done is to reaffirm that this is something that I'm not going to tolerate. And that I'm going to learn ways to stop, to communicate, and decide when it's appropriate just to ignore and move on. But most of it, become an advocate of the culture and the way I want to be treated and treating others the same way. OK, same question to Dr. Cruz. I mean, I'm sorry, Dr. Portugal. So yes, I've been the target of microaggressions in my career. And how I handled it is, I think, number one, just identifying that it is a microaggression. And it's actually not so much an issue with me, but of the action of the aggressor. Also, as mentioned before, leaning on others that were present has been extremely helpful. And then actually taking action to, number one, identify that action is not tolerated within the group. So actually speaking up has been really big in handling it. Thank you. Same question to Dr. Williams. Unfortunately, yes, I have experienced microaggressions. And I think an earlier speaker really eloquently said, it really depends on your level and also who it's coming from. And so when considering how to handle it, if you feel that this is a professional colleague that you are a bit more familiar with, sometimes I found it helpful just to ask them to explain that further, what they mean by this, and kind of call attention that that may be a little bit off. But being that we are often minority and don't often can get too familiar with some colleagues, I've just learned, honestly, to just try my best to just identify it for what it is and kind of move forward in knowing that these can come from this person. And just be aware that I have to present or prepare in a certain way to kind of reduce or minimize when that happens. But a very important part is just self-care and affirming yourself, because those things will come and they'll slowly chip at you and your confidence. But if you take the time to just do self-reassurance and self-checks, they don't bother you or chip you as much. So now we will have a discussion on mitigating strategies for targets and organizations. Next slide. So this question is for Dr. Portugal. What is the dark triad? And how does it relate to workplace bullying? So the dark triad was once described as partially inheritable traits that can be viewed as dispositions to engage in self-interested and antisocial approaches to attaining an individual's goals of their professional, interprofessional lives, interpersonal lives. The dark triad describes three characteristic personality types, one being narcissism, the other being Machiavellianism, and the last being psychopathy or antisocial. Without going to too much detail about these three, but the narcissist seeks praise and uses extroversion, openness, affiliative humor, high emotional intelligence, grandiosity, and pride, whereas the Machiavellian will lose low extroversion, lack of fairness, aggression, self-defeating humor, low cognitive empathy, vengefulness, and hostility. And the antisocial, or one expressing psychopathy, has low conscientiousness, lack of fairness, dysfunctional impulsivity, and limited self-control and vengefulness as well. It's important to identify these three, as all three use bullying as a tactic among many other tactics. And it's, I think, very important to identify when you're interacting with an individual that could be very disruptive to a group or even an institution. Our next question is, what mitigating strategies do you recommend for targets of workplace bullying? Let's first start with Dr. Williams. So, once again, it falls back to exactly who are you talking about and where you are as far as your level or where you are in your professional journey. I feel like for our younger colleagues who are still in training, when dealing with somebody who you feel is, you know, being a bully, the first thing is to talk to, if possible, an advocate who's within your area who can possibly help to balance things, either in the present time or an advocate or a mentor who can guide you or speak on your behalf, maybe privately with that person who is bullying you. But if you feel like you do not have an advocate who is either local in the area or a mentor to speak with, those are things that, unfortunately, we have to bear alone, but we have to be mindful of how to identify and also how to privately deal with as far as what you will do, as I said before, about your mental state and your self-care. I feel like what bullies don't understand is that the little ways that they hurt their providers in turn will hurt the patients that they care for. And so you have to be a proactive person in order to know how to identify it and know how to counter it with facts and truths and just personal self-care. For those of us who are a bit older, but maybe earlier in our career, I think it's important to once again do similar kind of tactics that you did as, you know, early on in your career. But now that you have some say and some power, it's good to make appropriate connections with other people who are either at least within your department and bring up, you know, some of your concerns, but in a way that you keep in mind, of course, our jobs and professionalism, like how this could long-term affect patient care. Because personally, for me, with some of the bullying that some providers can engage in, ultimately, you know, I'm a big girl, I can heal, but they were actually blocking and impeding patient care. So if you notice that these tactics are, you know, in turn, not just affecting you, but the quality of care that you can deliver, one clever way to kind of help to mitigate it is highlight how it is affecting the organization as a whole. But I don't want to take up too much of the time, I'll leave some time for some of our other colleagues to speak a bit further. I totally concur with you, Dr. Williams. Oh, sorry. No, go ahead, Dr. Al-Awadi. Yeah, so I totally concur with you. Can be more like you just nailed it, basically acknowledging that there is a problem is part of the solution and explore your options, how far you want to take this and move on with it. And definitely, if your department is open to it, you should have that clear conversation. And at the bottom of it, as you said, it's all about patient's care. We can bite the bullet and we can move on, but we know that there would be someone else who would handle the consequences, which would be the patient, let alone the organization part, which I will leave it to my colleague. It really depends on the person and how much bullying they had to handle. Are they going to take it to a legal part? Are they going to make it formal? Because you got to keep in mind, at the end of the day, if it goes to the chain of commands, if it goes to the higher levels, there are consequences that sometimes are irreversible and you got to weigh that and you have to weigh all your options before moving forward. Thank you. So our next question is for Dr. Cruz Jimenez and Dr. Bosque. What mitigating strategies do you recommend for organizations? So in my case, I'm the designated institution official. So among the strategies that I use is first, that you need to believe in the message that you want to send out within your organization, and you have to be clear that you're going to be a model that everybody's going to be observing. So the first thing is that you need to make decisions about your values that you want to convey as a professional, as a human being. The second thing would be to create a community. There are people out there who will be observing as you, behaviors of others. And I always tell my kids and my colleagues, you know, there are a lot of good people in the world, more than people that is not good. So we need to find those allies out there who believe in the culture that we want to transform, and we need to strengthen them, empower them, find out leaders of influence. In our case, I started with the residents forum, with chief residents forum, in which we started having conversations about dynamics, toxicity, the learning environment, the values, and how we could work together. And it was very interesting that they were all aligned on the vision of the environment that they wanted to attain. So we started having conversations. We started small with chief residents. We deployed that to other residents. And we included, obviously, the faculty, who are the models that people are looking up to. And obviously, we need to know that cultural changes do not change from one day to another. This is why we need to be clear about the values that we want to convey, because it's going to take time, but it is these alliances that are going to help us work together towards the world that we want to attain. Dr. Bosk? Thank you. Thank you, Mark, Dr. Cruz-Jimenez, for that. I think we also need to be aware and hold accountable our institutions. Some institutions out there say that they have a zero tolerance policy, but then when you go in and start asking, so, you know, like, so what's a pathway to report? Or how are we holding the parties accountable? And sometimes people may get fired, but there's actually not a sense of restorative justice in a sense. So one of the things that we can ask our organizations, especially if they're saying that, hey, we're not going to be tolerating this in our workplace, this is not going to be tolerated in our environment, in our learning environments, it's actually measuring the current state, right, of bullying at the organization, get data, you know, and for example, in my previous institution, the medical student graduation survey reported that there were some concerns with unprofessional behaviors in the learning environments of the medical students, including bullying during the rotations and feeling that the university did nothing. And technically, the medical school had a reporting mechanism, technically, there was a way to report these things, but it was mostly it was anonymous posting, and nothing would go back to the person to the victim of the microaggression and the bullying. So there was a task force that was developed by the university to discuss learning environments and professional behavior stored medical students among residency and faculty members, because then the residents were modeling some of these behaviors from their faculty members. And just like Dr. Cruz was mentioning, you know, like, yeah, we have to be positive models, but we also need to be aware that there's some faculty members out there that are modeling these behaviors to the residents, to the trainees, and that's going to trickle down to all the levels. So you know, so after we gathered the data, so we really wanted to have, like, more actionable steps, right. So after creating data and having this task force report, etc, there was a decision of the university with the needs that we are basically showing, there was an ombudsman's office that was created in order to manage these professionalism issues that we understood medical students bullying is just one piece of the pie. How are we going to hold accountable these faculty members when there are staffing privileges and all of these additional institutional structures, systemic structures that are part of the issue. So by doing this, then we also, so the task force allow a procedure to enable reporting the incidents to be able to contact back the parties, the victims with anonymity through the ombuds office. We were able to enforce the procedures to keep accountability for university faculty members involved in medical education. And then it's also really important to educate back right so you want to have sessions with the medical students with the residency program directors, regarding definitions of professionalism. How to be aware of inappropriate behaviors like we were mentioning sometimes it happens and you're like, wait, did that happen. Did I make that up. Was it just me or you almost need to check with other people. So if you educate people on what's appropriate and what's inappropriate behaviors that are not going to be tolerated that may be present in the environments provide tools for identification bystander training, how to report. What does the report entail actionable after reporting all of these are all different things that as organizations and institutions and programs, we can put together in order to mitigate and workplace bullying and microaggressions. Thank you so much. So now I'm going to turn it back over to Dr. Velez who will discuss mitigating strategies for targets. Thank you. So we put together a little summary of the different mitigating strategies for targets based on the discussion we just had. So recognizing that bullying occurs and try to recognize it and name it, put a label on it. It's important to know in order for us to heal properly. You can find a trauma informed mental health professional to consult and just to vent. It's very healthy to vent. If you're thinking about legal options, you can rent an attorney. You can start networking to find your next job. If you already know you're in a hostile workplace environment, documenting the incidents is important so that you can keep track if you are going to proceed or report it to higher up. I also like to try to figure out what's the cost of workplace bullying. So to create a business case, if you're having X amount of turnover, how much is it costing the institution to keep that bully? A lot of times, if you have the courage to report it, don't be surprised if you get fired. They retaliate against you. So just be prepared. Prior to doing that, I would consider just living on your own terms instead of actually reporting it. You have to weigh the risk and benefits of doing, of reporting it versus just managing it independently. Rehearse for your interview, just if you're getting another job interview, to say the reason why you departed. The main one that I would say is just trying to disinvest. Like I mentioned before, your identity, if you're going through that, we tend to put a lot, invest a lot in the identity. Your professional and personal identities might be intermersed, so try to disconnect one versus the other. Grieve and try, a lot of times the targets of bullying tend to be very benevolent. They tend to be over sharers. So just be cautious of what you share and how you share it so that it's not used then against you. We've outlined some of those strategies and then for organizations, just measuring, like Dr. Bosco said, measuring the current state of bullying within the organization, creating anti-bullying policies, try to form informal resolutions to bullying prior to having a formal enforcement as well. So you can have both informal and formal. I like the restorative justice instead of zero tolerance, because if you have just one incident, that person, if you educate them, they might be willing to change. With restorative justice, you can include both the target and the perpetrator and discuss it through mediation. Providing education once you establish those policies and procedures, and then just optimize accountability by promoting the people that are actually good supervisors and good managers. These are the references that were used throughout the lecture. And these are the contact information for our panelists. If you have any questions after you've seen the lecture, I do want to open it up now for questions of the audience, if there's any questions or comments that you would like to address with our panelists. So I will read the comments that are in the chat so far. So the first one is great point about self-care and affirming yourself, all excellent points being made. And then the second one, this is from Dr. Cruz Jimenez, we incorporated leadership development training for new trainees. We created projects in which there was a mixed composition of disciplines. So they would learn to know each other and work together. We started creating shared learning lessons. So please, as Dr. Pélez just stated, any comments, questions, please leave them in the chat for our panel. So we have a question from Dr. Merritt. How do we get this to the wider academy? Board and program director training, bring through the DEI committee. Do any of our panelists want to respond to this question? I think Dr. Pélez is part of the DEI program, so I don't know if there has been a discussion with some of the leadership of AAP Manor as the academy in how to, again, like what as an organization, right, we can do in order to react and provide these tools and strategies to the, for example, the residency programs, the hospitals out there, et cetera. I know that within the DEI committee, it is one of those difficult topics that we've discussed. I think that we would be more than open and willing to try to establish first, how many people are experiencing workplace bullying so that we can provide strategies in order to mitigate it and do it more as an organization versus just a committee. So I don't think that we've developed anything as of yet, but we are open and willing to disseminate it throughout the academy and to a wider public. And I remember one of our networking sessions as the Latinx Society community, one of the things that we were discussing was, is there any sort of like leadership training track for minorities within the academy to be able to provide us, some of the members that were dealing with this day-to-day with resources and tools to be able to build our leadership skills, but to be able to grow within this environment. So excellent question, Dr. Merritt, thank you for bringing that up. I can tell you that there is a researcher idea cooking in my brain right now, but I'll keep you posted, Hank. Okay, we are at time, but if we have one last burning question before we move to our networking time, I'll go ahead and allow someone to ask a last question. Okay, so I want to thank you again for joining us for this session. We have one more last comment. I hope that some of you will participate in the critical discussions in December to bring up importance of bias equity in our field for our patients and how we interact with each other. I think that's very important. So we will stay on this link for networking.

workplace bullying

impact on individuals

impact on organizations

strategies to mitigate

recognizing workplace bullying

support from mental health professionals

clear policies and procedures

microaggressions

educating individuals

restorative justice approach