Shevonne Matheiken (SM): The Psychiatric Trainees’ Committee of the Royal College of Psychiatrists is proud to present You Are Not Alone, a podcast series covering a range of topics affecting the well-being of healthcare professionals. There is a lot more talk about mental health and well-being since the pandemic began. However, well-being is complex, dynamic and personal. It is not something that can just be solved with resilience training or mindfulness. Both those things have their place, but concepts such as intersectionality explain why there is so much more to consider while discussing the well-being of healthcare professionals. This is what we hope to do through our conversations.
Episode 6, Doctors of Ethnic Minorities. Welcome to the final episode of the You Are Not Alone series. I’m Shevonne Matheiken, a specialty trainee in psychiatry in the East of England, and I’m delighted to be joined by two very eminent guests who have contributed in so many ways to the profession of psychiatry.
First, we have Professor Femi Oyebode, who is a professor of psychiatry at the University of Birmingham. Psychiatrists young and old may know him first and foremost as the author of Sims’ Symptoms in the Mind textbook, which I’m sure has sparked an interest in many medical students to choose psychiatry. He’s also written other books, including Mindreadings as well as six volumes of poetry. He has a varied research interest in clinical psychopathology, medical humanities, application of ethics to psychiatric practice, to name a few. He received the RCPsych Lifetime Achievement Award in 2016 and an honorary FRCPsych in 2019. Professor, thank you so much for joining us today.
Femi Oyebode (FO): Thank you.
SM: We’re also joined by Dr Shubulade Smith, who is a consultant forensic psychiatrist at the South London and Maudsley NHS Foundation Trust. She was awarded the RCPsych Psychiatrist of the Year in 2019 and also awarded a CBE [Commander of the Order of the British Empire] the same year. She’s one of the two presidential leads for race and equality at the RCPsych, along with Dr Rajesh Mohan. Her research interests also include black mental health, side-effects of psychotropic medication, physical health in severe mental illness, women’s mental health and mental health law. Thank you for joining us, Dr Smith.
Great, so this is a really huge topic to cover, but a very important one and we feel very lucky to have you both join us today. It’s also interesting that we are recording this during Black History Month, even if the recording won’t be out before the end of October.
So, I wanted to start with ‘white privilege’ as a term. I moved to the UK from India, and I’ve probably not heard this term prior to that. And it’s been one of the things, along with learning various other terms related to race and equality, that’s been new to me. I wondered if I could ask your thoughts on this term, as well as how you would explain this to someone who has not heard of it.
So I’ll come to you first, Dr Smith.
Shubulade Smith (SS): So, the thing about the term white privilege is that it’s actually… really, it’s an academic term. And it’s a term that’s been around for decades, actually. Essentially, sociologists have been studying the concept for years. And it does mean something quite specific, and it does refer to the advantage conferred by having skin that is white, essentially. And this is a worldwide advantage born out of the European dominance across the world in terms of colonialism and the European dominance in terms of… Well, essentially, it’s imperialism.
And I think the difficult… I actually personally find it an unhelpful term because it’s been bastardised, I think – in the same way that people use the word ‘stress’. It actually has a very specific medical meaning. And the term white privilege doesn’t mean… It’s frequently misunderstood and misinterpreted. And in that sense, that’s why I think it can be a bit unhelpful. Really, what it is to do with is the disadvantage that occurs if you have non-white skin. And I think there could be… We have to acknowledge that now it’s an unhelpful term because it creates too much division and because people don’t understand what it means. And unless you’re going to be able to explain to people what it means (you’ve got the opportunity to explain to people what it means when you use it), then using it as a shorthand and then dismissing people who don’t understand it isn’t useful. Because all that happens then is that there’s people just getting into an argument when you’ve got someone who is white working class from Middlesbrough, brought up on a council estate and feels that in no way they’ve ever had any privilege in their life, and you say, “Yeah, but you have white privilege because you’re white.” And it’s very hard for people to understand what that means. They don’t understand that what that means is, if they thought to themselves, “You know what, I’ve got a couple of hundred quid; I’m going to buy myself a package tour to Croatia”, they wouldn’t have to worry that people are going to look at them funny in the street or that people might spit at them and stuff like that.
So, in some ways it would be great if we could think of a term that conferred the disadvantage that exists for people who are not white, rather than thinking about the advantages that people who are white might have – because so many people who are white don’t feel that their lives are advantaged in any way at all. But essentially, it’s a difficult term because I think it’s misunderstood too frequently.
SM: Thank you, Dr Smith. That was perfect to explain what my dilemma was. Because I was wondering if it is useful as a term – or can it be misunderstood, often when trying to have these uncomfortable conversations in terms of the differences in people’s life experiences?
Professor, do you agree that it’s an unhelpful term or did you have a different view on the term white privilege?
FO: Yes, I think if I might say that a way to think of it is just to try to understand what the term is saying. And so, I was born in 1954, so I lived for six years as a subject of Her Majesty in a colonial country called Nigeria. And you might think that the post-colonial period is a great difference from my first six years of life. So, to understand these issues, it doesn’t do any harm at all just to give an example of where these matters… where they’re speaking to and where they’re coming from.
So, very many years ago, I went with a group of psychiatrists. I think there were five or six of us travelling from the UK to Boston and it just happened to be that on that occasion there was a snowstorm. So, the flight which should have arrived in New York, arrived instead in Toronto. And I was the only person travelling on a non-British passport. And we arrived there by mistake. We… You know, the plane hadn’t intended us to land in Toronto. And the Canadians acted as if I had deliberately arranged for the plane to land in Toronto. And it was embarrassing, very embarrassing for me and for the other colleagues who were all white psychiatrists. And we were delayed precisely because they asked me why I had stopped in Toronto. Why would they ask me that question?
So, I give that example in order to make the point absolutely clear that the arrangements we have in the world at present privilege some people. And that’s just a matter of fact. That’s not an accusation; it’s not a statement to make anybody feel guilty or ashamed, or anything of that sort. It’s just a matter of fact.
My children’s cousins, who live in Lagos, who are as successful – intellectually as successful – as my children, have great difficulty travelling around the world and my children don’t have any difficulty travelling around the world. So, these arrangements which have occurred, which were prevalent during the imperial period, are still present in this post-colonial period. And the advantages that some people have which are implicit, these advantages need to be made more explicit so that people recognise that we live in an unequal world. And the ways in which these advantages affect us, and the ways in which they adversely affect us, are myriad and subtle and insidious and… I’m sure you’re going to go on to talk about this in a minute, but they also attack our self-esteem.
So the other example I’ll give… And there’s no apologies for these terms, and actually these terms weren’t invented by black people either: it’s the American Anthropological Society that actually codified it, and that’s not black Americans. So then, there’s no shame in these terms. There’s no apologies for them or anything of that sort. So, the other example I want to give, to show you how… I’ll give two examples actually.
So, for example, you’re reading a text, an anthropological text – and I read that because that’s just how my mind works – and every single page, on every single page there’s an assault on my self-esteem. People have to go out of their way to say that non-white people are primitive. And they’re doing that totally unconsciously. They’re doing it casually. They’re doing it gratuitously. It is extraordinary, the degree to which people do that.
And for all sorts of reasons I wanted to read Marguerite Yourcenar, who’s a very, very famous French novelist. And she’s chosen to write something she calls Oriental Tales, and she takes Indian folk tales and Indian myths – and she’s not translating, she’s re-formalising them. And she’s writing about Kali, whom you will know, Shevonne. So, she’s writing about Kali, and in her version of Kali, she wants to say: Kali is a woman who is very lustful and has sex with different people. And so she says in this passage that Kali had sex with farmers, and she had sex with the lowest-caste people in India and this, that and the other. And then in the last section of this – and it’s not a translation; it’s her own writing – the last clause, it says “and has sex even with a black man”. And the word ‘even’ does all the work for you.
So, the point I’m trying to make there is that we have to accept that these matters are pervasive, that these matters occur over time and that they are thoughtlessly done. And I could go on and on and give examples. But you’ve got the point. You’ve understood the point I’m making. So these terms that we are saying, I agree with Lade that these terms can be unhelpful. But they are helpful to the degree that they make explicit something about the structures of the world that we currently inhabit.
SM: Thank you, Professor – and that did also remind me of things that you realise as you journey along life as well. Growing up in India, something I reflected on since coming here was how, although arranged marriages were very much the norm when I was growing up, there would be the odd person who met somebody and got married and, if that was as a brown person at least… I can’t generalise; the patterns were that if that was to a white person, that would somehow still be considered “Oh, that’s exciting”, that kind of way – but if it was to a black person, that’s not how it would be seen at all. And I never thought about it till I came here and started living in a very diverse community, and so your story about Kali made me think about that. So thank you so much for sharing that.
And I guess my reflection was on a small clip John Amaechi had done on white privilege to sort of resolve that misunderstanding that Lade was talking about, when people just hear the term – because he talks about how people would think, “Oh, are you trying to say I don’t have a hard life because I’m white?” And he goes on to say, it’s not to say that at all: it’s basically the absence of an inconvenience or an impediment which, if you have that privilege, you don’t notice that you have it. But it doesn’t mean you don’t have a hard life. It just means that if you have hardship and suffering, that’s not due to your skin colour. So…
SS: Can I just say something, actually? One of the things I’ve always thought about white privilege is, the problem is – in a sense – that what it doesn’t do is… It fails to acknowledge the ongoing and all-pervasive disadvantage that exists if you’re not white. And again, yet again, it still talks about what white people have, and it’s a reference… And, actually, my view is that what you get if you are white should be what everyone gets anyway. That should be the norm. It’s not that it’s above and beyond, and that you as… Everybody should have the – what we describe as an ‘advantage’. I don’t think it should be an advantage. I think it should be the norm. Everyone… It’s described as having an advantage of being able to walk anywhere around the world; certainly if you’re a white male, you can go anywhere around the world and no one’s going to look at you oddly. They might say… You know, you’ll always be welcomed in. You’ll have a place to stay, actually. If you’re not white, you can’t guarantee that. But that should be the norm rather than be seen as an advantage, and so I kind of feel that the descriptions that are given are not sufficient to convey the disadvantages that exist for everybody else, rather than the advantages that exist for someone who’s white, if that makes sense.
SM: Yes, it makes total sense, Dr Smith. Thank you so much. And I guess similar to that, what you were saying, is in the wake of the Sarah Everard murder there were a lot of people saying things like, “If the world we live in was different, what would you do?” And there were women saying things like, “I would be fine to go to a beach and sit there by myself at midnight”, and simple things which then sort of became a movement where men started thinking and walking in the other person’s shoes and seeing what privileges they had gender-wise.
So, taking this conversation about the current world we live in to our workplace – the NHS workplace, to be more specific – what do you think about identifying microaggressions? So, especially people who maybe worked with people who were of the same ethnicity and then coming here and working in a very diverse environment. How would you advise them on how to pick up microaggressions which are harder to evidence than more overt racist behaviour? How would one go about that?
I’ll come to you first, Professor.
FO: As you know, Shevonne, the term microaggression is a relatively new term. And I suppose it’s trying to say something about behaviours which are relatively low-level behaviours which indicate some degree of hostility, about which obviously if you were to identify them the person would – could – say very clearly that they hadn’t intended it in that sort of way. I suppose that’s what it’s supposed to be about.
I think the first thing to say is that the world is very, very complex and there’s a question you’ve got to ask yourself about where your barrier is in terms of what you object to. And I think there are behaviours which go on every day, and there’s a question in your mind about which ones matter. So, I suppose the first thing to do is to recognise that there may be behaviours which are intended to be hostile, and that some of these behaviours may not be necessarily consciously or intentionally displayed. That’s not to say they’re not harmful.
And secondly, that these behaviours, they’re so prevalent, so ubiquitous, that the question of when you actually respond to them is a question that you’ve got to address. But the real interest from my point of view is how you protect the self, because I regard them as assaults on the self. I regard them as assaults on self-esteem. I regard them as assaults on sense of worth. So… Whether or not you identify them, whether or not you tell the person, whether or not you object to them – the real question is how you protect sense of self in these sorts of circumstances.
SM: Thank you, Professor. That’s very thought-provoking, especially the bit you said about the impact and the assault on our own self-esteem. Because I think it’s very draining, the little experience I have, when you’re trying to figure out a certain behaviour or an incident, when you’re trying to make sense of it. Is this something else? Or am I just imagining this? Should I be doing something about this? Is it worth my mental energy?
What do you think, Dr Smith, about this?
SS: I think one of the things that’s important to note is that there are, you know, these… They are daily. They are all-pervasive. They’re extremely subtle. And they are insidious. And these microaggressions can occur directly to you as an individual, but I think more frequently what people will see is them occurring to other people who are marginalised within the environment. And, actually, I think the one… Especially now; I suspect that those of us who are older probably don’t notice them or have had to put up with them a lot more and so don’t deal with them when they happen to us individually. And I think people who are younger are much more likely to pick them up and say something there and then, and say, “Actually, that’s not really OK” or “Could you…? This is how you say my name”. That kind of thing.
I mean, frankly, people say my name incorrectly all the time and I have just been used to that – funnily enough not when I was little, but certainly since I’ve been at… Actually, more since I’ve been a doctor; people say my name incorrectly all the time. People I work with now still say my name incorrectly. It doesn’t matter how I introduce it. And the way I deal with it, I say, “Well, if you haven’t got a Nigerian accent, it’s difficult to say.” And it’s lovely to hear Femi say my name, for example, because he said it so correctly. And it’s a dreadful thing to hear people with – it’s often people with southern accents, but it’s not necessarily southern accents – saying my name, because they just say it like, you know… Anyway, it doesn’t really matter how they say it, but it’s said awfully.
In a sense, the issue is not when you say to somebody, “This is how you say my name.” It’s when they deliberately, completely, you know, continue to say it incorrectly because they’re not choosing to hear what you say. They’re not choosing to make the effort. But that’s the kind of thing that I think is easier to pick up and to say something about, and younger people do that better.
The issue for me is more the microaggressions that occur to everybody else and that you’ll see happening. It might be in a ward round or in a committee meeting type setting, a meeting setting, and someone says something, it’s a throwaway comment, a throwaway joke: “Oh, we know about these people.” And it’s actually very derogatory, really. And the shame and the embarrassment that someone will feel – but then there’d be the additional shame and embarrassment to actually say something about it. But the fact is, it does require courage and it requires bravery, and it requires practising a way of saying something at the time. And I say… Well, we’re psychiatrists. We have to do this all the time, say things to people that they’re not going to like, but we say it in a way that is more palatable. And you can say to someone, “I noticed that you mentioned there that this person may not be able to manage that activity because they’re a bit lazy. I’m not sure if you realised, but that kind of implies that you’re saying it’s something about them being from this particular ethnicity. I just want to be sure that everyone’s in agreement that that’s not true, is it?” And you know, you can make it so that everyone has to agree with that position, but it still makes the point without necessarily embarrassing that person. It’s hard for you to do, but it’s better to do it in the moment, because if you don’t do it in the moment, then very quickly people say, “That’s not what he said, is it?” Because the fact that they’ve accepted it at the time implies that it was OK. So if you wait until the moment is gone, then it is too late.
It does make it easier again when you get to the stage you don’t have to worry about your job anymore, and so there is a kind of curve that happens. You know, at the beginning it’s hard. In the middle it’s even harder. But when you get to the end and you’re about to retire or you’re retired… I mean, now I just say, “[Coughs.] Er, sorry, what did you just say there?” I’ll make a joke of it. “Did you actually say that you thought this man was lazy because he was black? I’m sure you didn’t, did you?” And I’ll make a joke of it, but it makes the point. And I would say you have to do it in the moment: it’s a dynamic thing. Otherwise, it’s lost.
SM: You make it sound very easy, but I honestly struggle sometimes, like with the examples that you gave very eloquently. And I also wondered, exactly what you said about, if that’s much harder when you’re more junior in the team, in the organisation, as compared to as you get to a higher position. And I wonder if that’s part of the barrier for more junior people to make these things heard.
SS: I mean, you’re right: it is more difficult if you’re junior. But I also know that if you recognise the microaggression and you recognise it, you recognise it. Then, as Femi said, it takes its toll. It erodes gradually your self-esteem and it gets harder and harder and harder.
And being the ‘difficult character’ is more likely to… It’s more likely that you’ll be ascribed the designation ‘difficult person’ if you come out with things when you’re so frustrated that it kind of is almost an outburst, and then it’s not said eloquently, et cetera. You’re more likely to be able to say something about it if you can say it in a controlled, measured way.
If you can make it humorous, humour dispels things, so if you can make it humorous, then do – and do it early and do it in the moment. Or make it a question. You can say, “I just want… I’m just checking something. You know you said that; is that about that particular individual, or is that a general thing?” Make it a question. You can say, “Oh, you know, I’m new to this job. I’m just wondering what you meant there exactly.” But if you can add humour to it… And you have to practise different mechanisms of… I mean, you know, different mechanisms by which you would point the problem out. But number one, you have to point the problem out when it happens; number two, if you can do it with humour, all the better; number three, make it a question.
SM: Thank you. That nicely takes us to the next bit about barriers to speaking up. We’ve already touched on a few, including being labelled as the problematic person bringing up issues. The other thing we’ve heard from colleagues, juniors, is fear of repercussion – and also that nothing would come out of it. So again, slightly related to that, chipping away in terms of how it drains you over time.
For example, the GMC [General Medical Council] training survey where we are encouraged to report things like bullying and any particular issues; my understanding is that if there are issues highlighted, it sort of goes back to your training programme sort of direction, and the people above you. So, in a way, partly one could argue it’s not really anonymous – and then you can justify why people feel scared, because it is in a way then identifiable, especially if you’re in a very small training programme.
So, I just wondered, what do we think are those barriers and how can we – or maybe people a bit higher up in terms of culture change – how can we change those barriers and make it easier for people to speak up?
I’ll come to you first, Professor.
FO: I mean, you’ve already said it all really, that these are difficult matters. I’m not very sure what to say in this sort of area of life. What I mean is that you’ve got to live. You know, you have to live – and therefore you have to choose your battles. And you don’t want to be a victim because a victim position is a bad position to be in. It’s very disarming if you are in a victim position; it doesn’t give you authorial agency. It imprisons you. So there’s a lot to be said for choosing your moment, really.
I take the point – and one’s got to be very careful – I take the point about injustice. You know, you’ve got to fight against injustice. And I’m very anxious not to come across as if you’ve got to be so compromised because you don’t want to fight.
There’s a Czech writer, Hrabal; he killed himself in the end and some people think maybe he fell from a block of flats, but he probably killed himself. And the whole of his life is to do with being… having not to be against the communist government. Because he’s afraid of physical repercussions of being against the communist government; he’s afraid of spending time in prison. But he’s also very, very deeply… a person with incredible integrity and who understands the nature of justice and all that sort of stuff.
So what I’m trying to say there is that if you make too many compromises, it’s damaging to sense of self. If you live in the world that we live in, the world attacks your situation. It attacks who you are. And so it’s like a never-ending kind of dilemma that one’s in. But even just saying that aloud is helpful for all the younger people to hear it, that you are treading a very, very fine world; that you cannot be too alert to insults because if you are too alert to insults, you can’t live the life that you’ve got to live.
You know, Toni Morrison says that these matters are sent our way to distract us. So that’s Toni Morrison’s way of thinking of it. And another way of thinking of it is James— Sorry to go on about literature, because literature’s just so very helpful.
SM: Not at all. It’s very interesting.
FO: You know, and James Baldwin said, the person you see is not who I am. So that’s James Baldwin’s way of sidestepping it to say, you see me as a black man in America, and you think I’m stupid, I’m not bright, I’m lazy – but that’s not who I am, you know. So you’ve got… You’re treading all this all the time.
So you’ve got to be alert to them, but not overwhelmed by them. And you’ve got to choose your moment and you’ve got to choose your battles. But all the time too, there’s all the other aspects of this, so it’s not all to do with complaints.
So, for example, in the culture we live in, being Afro-Caribbean is not particularly esteemed, but some of the greatest thinkers of the 20th century are Afro-Caribbeans. Sir Derek Walcott is a master of the English language, and he’s not English, you know? So, you have to remind people of that and you are doing it in a throwaway sort of way in order to guide gradually, affect the other person’s perception – which is an erroneous perception. But you don’t do it by sermonising; you’re doing it just like we are doing, talking and reminding ourselves of the things that matter, and indicating to ourselves the facts that you might not think highly of us but we do know that we are humans and that we have value and things of that sort. So it’s a complex way of living, but you can’t unless you want to go back to where you’ve come from, if you want to think of it in those ways. I’ve lived in Britain 42 years: I’m not going anywhere and therefore what I’m going to have to do to live here is adapt to it in such a way to the degree that I’m not invalidated, which is what we are trying to ensure that we’re not.
SM: That makes a lot of sense, Professor. You actually reminded me with your earlier example as well about getting used to things, I used to always think about the very long queues – almost three hours – at Heathrow every time we come, for anyone without a British passport. And we would often see the empty queues on the other side where people can just walk through, but the officer still wouldn’t sort of, you know, help to make this queue any shorter. But it just somehow reminded me about what you said about picking your battles and where you think change might happen.
And I guess also it brings in about intersectionality because if you have multiple characteristics that make you… I’m not sure if ‘vulnerable’ is the right word. It makes you think that there are even more reasons why you don’t want to go through with this, so you need to pick your battles carefully in terms of consequences and just keeping yourself sane, I guess. It makes it even more tricky.
What do you think about this, Dr Smith?
SS: I wholeheartedly agree with Femi, actually. There is something about… You almost have to have a policy for yourself, don’t you? It’s a bit like those of you who do Twitter and stuff like that. You’ll have a policy about how you tweet. There’ll be some people who tweet about personal stuff and there’ll be some people who only tweet about work stuff or only tweet about articles they’ve read in the news, et cetera. You almost have to have a policy because you are going to have to protect yourself, and at the same time… And protecting yourself doesn’t simply mean keeping your head down. And you mentioned SAS doctors [staff, associate specialist and specialty doctors] and international medical graduates in particular who have the big problem of if you keep your head down then you’re just ignored and you are overlooked – and repeatedly overlooked, actually – and you’ll be overlooked forever. You’ll never be properly seen – as James Baldwin said – you’ll never be seen for who you are. So completely ignoring everything and just putting up with it isn’t enough. And also it does erode one’s self-esteem.
And funnily enough, keeping to the literary aspect, I’m really reminded of a quote by Viet Thanh Nguyen. He’s actually a professor. He’s a Vietnamese American who’s a professor of English and ethnicity studies. And he says, while it’s best to be loved, it’s… How do you say it? While it’s better to be loved than hated… That’s it: it’s better to be loved than hated, but it’s far better to be hated than ignored.
And just to be… And that thing of just to be not even noticed. If someone hates you, at least they have an emotion about you. They care about you as an individual, even if the thought they have about you is a negative one. If they love you, then that’s obviously the best position, but to not even be noticed, you know, to not even be counted as a human being, to make no impact, is a dreadful thing. So it means if you don’t have your policy about what your battles are going to be, then it means that you do particularly risk – especially if you’re on one of those small rotations, you’re an overseas doctor or a SAS doctor or whatever – you are going to end up being someone who isn’t ever seen for who you are as an individual, even though it’s a small group of people and they just… So what does that mean they see you as? They just see you as this brown or black placard? You know, a cardboard two-dimensional figure who is there to write the prescription charts and clerk the patients like some kind of workhorse robot, but you don’t get seen as an individual. Now that is quite a significant erosion on you as a person and so…
I mean, actually, back to the question of, so how do you manage it? Then you have to actively have your policy about where you’re going to speak up and what you’re going to speak up about, and everyone is going to be different because everyone has different… You know, some people are much bolder in themselves and will be able to speak up for everybody, and you might only be able to speak up for yourself. And there’ll be some people who might decide, “Actually what I’m going to do is, I’m always going to speak up when it comes to the patients”, and that might be the easiest thing, because if you speak up about microaggressions that you see happening to the patients, then it will have an impact on people’s thoughts about other people who might look like those patients.
And that kind of links in again with white privilege, because if you… That’s an example of white privilege, actually, because you don’t necessarily… You’re not going to be subject to the microaggressions, so you don’t have to have a policy for how you’re going to deal with them in your life. That’s actually quite a nice thing, a nice situation to be in. Although having said that, though, there’s no reason at all why if you’re white, you can’t speak up if you notice a microaggression.
And the other thing to note as well is, it’s not… Microaggressions are not just the domain of white people. Microaggressions happen… Lots and lots and lots of different types of people unfortunately can be microaggressive in their behaviour to others – and that’s a function of internalised racism, I’m afraid, but there we go.
SM: Thank you, Dr Smith. Very valid points, and I guess that brings us onto things like unconscious bias training. Because it’s not that only white people are racist. Like you were saying – like, I know that brown people are racist too.
Is there value in things like bystander training, about speaking up for others? Especially, you spoke about the wider picture where patients… our duty to patients, about the quality of care and things like this affecting the quality of care they receive. Do you think there’s value in bystander training, unconscious bias training, things like that?
SS: So, it’s controversial. Bystander training, yes. I think it’s a really, really, really useful thing because it does help people to not only understand the issue, but also if it’s good bystander training (the stuff that I’ve seen, anyway), it does provide people with practical strategies to manage difficult situations – you know, discriminatory situations – when they arrive. And not just racist behaviour, but all discriminatory situations. So, bystander training: big thumbs up.
The difficulty with unconscious bias training is it’s generally done very… You know, there’s massive variation in quality. It’s often based on just making people aware of their unconscious bias, and the whole point about unconscious bias is that it’s unconscious; you don’t know about it! You know, we all have our prejudices and we haven’t deliberately decided, “Right, today I’ve decided I’m generally going to dislike people who wear brown corduroy jackets.” It doesn’t come about like that.
What happens is that because of the all-pervasive signals that we get in our society… Sometimes it will be a familial thing that reinforces that; there’ll be role models in our family or in our lives that reinforce prejudicial behaviour, and it becomes part of what you do.
Everyone knows… I mean, I remember going away. Where was it? We were sightseeing by some very famous palace somewhere, and we were sitting on some steps and some tourists walked by from a particular place. It’s myself and my daughter. And they were walking by and there was this little girl with them who was dancing around with an umbrella and she danced into us. She looks up from her umbrella. She sees it’s these, you know, black people, and she literally jumped backwards and then ran – ran to her family, and they cowered from us. And I was thinking, wow. Wow, what on earth are you being told? I mean, it was quite incredible, but it told me that that little seven-year-old girl has had all sorts of messages about what a black woman and her young teenage daughter could do to her. And she will grow up with that bias. And at some point hopefully in her life she’ll become aware of that – but that initial instinct to jump away is always going to be there, and she will have to work quite hard to get rid of that. Even if she intellectually knows and in her heart of hearts knows it’s not the right thing to do, it will nonetheless be unfortunately a very unconscious thing, so I’m not sure how unconscious bias training, making her aware of her prejudice, is going to help. What she would need is behavioural strategies to mitigate against the unconscious bias that she has, and that’s what’s needed.
So there needs to be a sea change in the type of unconscious bias training that’s available. My view would be, let’s start thinking about behavioural interventions that mitigate against an inevitable happening. Which is something you can’t… You can’t, just, you know, dispel your unconscious bias when you’re 45 years of age. It doesn’t just go away.
SM: Thank you for sharing that powerful story. And I guess that also highlights how important it is to have these conversations very early on. I am still learning but I try to talk to my two boys about these conversations. And I’m really thinking of a positive. They’re in a very diverse part of England; they have children who speak 42 languages in their school and there are lots of interesting conversations and opportunity for conversation because of that diversity.
Professor, what do you think about things like unconscious bias training and bystander training? Of course, like with well-being, I think the risk is of it being a tick-box exercise.
FO: Yes. No, I couldn’t say any more than Lade has already said, so not much more to add. I just think that it moves beyond the training to our roles as people who sit on appointments committees. And in my day when I was chief examiner, the Royal College of Psychiatrists and training was very, very keen to ensure that the examiners were trained, and the whole idea for that at that time – this is going back; I stopped being chief examiner in 2005, so it’s fifteen, sixteen years ago – and the whole purpose of my training was to talk about fairness because I thought that’s a very British thing to speak of, to use that term, that the whole purpose of an exam is for it to be fair.
But the videos which I created allowed me to not use the term ‘bias’, but to get people to tell me whether they passed somebody or not and tell me how well they passed them – so that sometimes they would say that they’ve given somebody seven or eight out of ten, and I would have given that person five. And then I’d ask them why did they do that? And then I’d tell them why they couldn’t possibly give that person eight, given what the person had actually done. And of course all of that’s done very nicely and very gently and done with humour and all that sort of stuff. But that work never once talked about bias, always about fairness. And never – or very, very rarely – did I indicate something about the characteristics of the person, even though I knew what the characteristics were that underlay the degree to which the person passed or failed, even though I thought they had passed or they’d slightly failed.
So that’s a long-winded way of coming to talk a little bit about sitting on appointments committees – at all levels, not just at trainee level appointing trainees and things of that sort – and very gently making sure that you summarise why the person ought to get the post or not. And very, very gently, with a kind of… Again, as Lade has said, humour is wonderful because it’ll allow you to say something about somebody who’s saying something which is totally, totally false, which is totally misguided, which is coming out of an accent – hearing somebody speaking a particular kind of way – and then making judgements about that, but not being aware that that’s why they’re doing it.
So you have to find your way of counterbalancing that within appointments committees and find a way to speak so that other people on the committee can see the value of the person who somebody is trying to dismiss, and so on. It takes a lot of courage to do that, but I’m not opposed to training; I’m just saying the training isn’t enough. We ourselves have to be able to do the work and act responsibly and act with courage when we’re in the arena where judgements are being made and where we can see that there’s an unfair judgement being made, not on the basis of somebody’s presentation, but on the basis of some kind of perception that others have of them.
SM: That is spot on, and I guess that is what I meant, because if we are putting the onus just on some particular training and we’re then taking the responsibility away from ourselves, isn’t it that these things should be everyone’s problem when we talk about gender things as well, like the different kinds of privileges? I know we’re focusing on ethnicity today, but it is important that we don’t depend on other things to solve these issues and that all of us have a part to play, and that all these things about different kinds of privileges and making the world fairer should fall on everybody. It should be everyone’s problem.
You’ve also made me think about another huge topic: differential attainment in various themes, not just exams. Again, this is to do with designation, ethnicity, country of qualification. And I know the College and other specialty colleges are also doing lots of work on this, but it then took me on to think about just well-being – because this whole podcast series was about a well-being theme on the various things that affect our well-being. And I’m reminded about the GMC’s report Caring for Doctors, Caring for Patients, and they talk about the ABCs for doctors’ well-being and the ‘B’ in that is ‘belonging’. And in a few of the other episodes as well, we’ve talked about civility, inclusivity – just the importance of feeling like you belong and being welcomed.
And I was also hearing at a diaspora organisation conference recently about the global shortage of doctors and healthcare professionals, and it’s a no-brainer that we should be treating people better, welcoming them better, inducting them better and also talking about the strengths they bring when they come in – not just that they are different people coming from a different place, trying to fit in to plug the gaps like Dr Smith was saying earlier.
So what advice do you have? Or any reflections about how we can make that better, like the culture change? Of course, it won’t happen overnight. Whether it be through allies, people speaking up, culture change – any ideas at all?
FO: Obviously it’s important to feel welcome. It’s also important to have a sense of belonging, because they’re two aspects of the same thing, aren’t they?
And so I come back to myself for a minute. You know, I’ve lived in the UK since 1979. And do I feel I belong? I suppose I’d say sometimes I do and sometimes I don’t. So that’s my way of saying that when you’re an immigrant – I know the term immigrant is now like a slur, but I am an immigrant – when you’re an immigrant, there are difficulties with how you fit in. And I’m not sure that I fit into Lagos anymore (because I was born in Lagos), so it’s not as if the problem is only to do with me fitting into the UK, because some of that problem is that I no longer fit into Lagos. And just to emphasise the point, I did a talk yesterday for trainees in Lagos and I thought that was very interesting because I came off at the end of it and I came and said to my wife, “I’m no longer Nigerian, you know.” And that made me realise that my whole approach, my way of answering the questions they’d asked me… My preoccupations were not the same preoccupations as they had. So it’s a complex world for those of us who migrate.
But nonetheless, I still agree with you, Shevonne, that being welcome is important. And I always give this example of the fact that I go to work in Singapore – and this was when I used to go to Singapore every year – and people will always come and meet me. And they would be so hospitable; they’d come out and ensure that in the evenings I wasn’t feeling lonely and that I wasn’t on my own and they’d arrange for me to come to meals and all that sort of stuff. And I have to work very, very hard to reciprocate when they come to the UK. I have to be there, I have to remind myself. Because I’ve stopped being as hospitable as I would be if I was living in Lagos.
And so there’s something about the culture that’s very diffident and very timid. It’s not that it’s an unwelcoming culture so much; it’s just that the way it expresses itself can make it – to those of us who come from much more hospitable places – can make us feel that we’re not being properly welcomed. So, everything we can do to improve that is worth doing. And those of us who come from, you know… The term we use is that we are materially poor, but we’re socially rich, those of us who come from Africa and Asia, who originally come from Africa and Asia; that we have this kind of willingness to be more receptive and more receiving of others. That aspect of our culture, we should bring that with us when we come to the northern hemisphere and we should retain some of that, and we should invite our trainees to come out with us for a meal and we should be…
You know, I was totally preoccupied with the families of the trainees of mine who came from India during the Delta outbreak in India. I emailed all of them who had gone back home. And the current trainees that I have who are Indian, I made sure that I asked after their relatives and a lot of them had lost relatives. And just to remind ourselves of the common humanity, and that it’s not… There’s nothing intrusive about asking how people are and how they’re getting on, and whether their relatives in other parts of the world are well and things of that sort.
So, that is something which we bring with us, because that’s just the way our cultures operate where we’ve come from, and I think maybe we should also be trying to use that to change how people behave, at least in our local areas, in the UK.
SM: I totally agree. The reason I did ask that was precisely those examples that you gave. Because when we hear stories of international medical graduates who’ve come more recently or still in the day, some of the stories seem very similar to experiences still happening 10 years ago in terms of being put on call straight away or being very socially isolated, and I guess there’s also a lot of changes in the way we are taught. I remember hearing you at the IMG [International Medical Graduates] conference for the first time, Professor, where you were talking about a PLAB [Professional and Linguistic Assessments Board] experience where someone’s asking a lady in a role play about postnatal depression and they were asking about “Oh, did you have a boy or a girl?” and sort of a bit of disappointment in the tone unconsciously when they said it was a girl. And you were sort of telling us that that is culture speaking; that does not reflect their history-taking abilities or as far as the exam goes, and that we need to be able to differentiate those things when it comes to assessment and things like that. I think those are really important points.
Dr Smith, did you have anything to add about the welcoming, belonging aspects?
SS: Well, it’s interesting hearing what you say. I mean, I was born in Manchester, so I’m born and bred in Britain from Nigerian parents, and the fact is that people talk about inclusivity now, but it was always about belonging. I never felt I belonged. So it’s not something about being an actual immigrant. I was always an immigrant and the way in which you deal with that as you’re growing older is… You know, for me, people would say well where are you from? I’d say I’m second-generation Nigerian. And that was good because it meant I had a connection with Nigeria. And I was lucky enough to go and visit Nigeria when I was younger, so I had a real connection with it, with real people who were there, and I knew something of it. But lots of people I knew didn’t have that, actually – didn’t have that connection – so they didn’t have a rootedness. And that was really important because, as Femi has said as someone who was born and bred in Nigeria, he doesn’t feel he’s Nigerian in the same way.
And that’s one of the reasons why people will, I think you’ll see now, people don’t have a rootedness, so they find a culture that they like the idea of. Ghana is a good example. You get lots of black Americans who latch onto Ghana because Ghana’s relatively safe and easy to begin with, or they’ll have looked through their ancestry and they’ll have picked out that one of their ancestors might have been Ghanaian, and they’ll change their name to a Ghanaian name and things like that. Because people are desperate to… When I talk about rootedness, what they want is a sense of belonging. They want to have a sense of this is somewhere I can say that I have belonging and I’ll be accepted.
And that’s something that, some people, they have that straight away because they’re born and bred in the place where everyone recognises them and is like them. And for others of us, you have to find your own place. And that’s one of the reasons why you get places like London and New York where people flock to them, because they can be anything and you can make your own families, really. You almost get a proxy family. So, you can be someone who is second- or third-generation Nigerian, who’s not quite Nigerian, not… You know that you’re never going to be counted as British because if you walk down the road in some little village in the outskirts of Kent, then people are going to wonder where you’re from. It wouldn’t matter how long… I could have lived in, you know, I could have been born there and lived there all my life, but there’s still people will ask me, “Where are you from?” They don’t mean… Because they don’t think I could be from there.
So there’s always going to be that sense that you don’t quite belong. Over time, that will change – for my children and their children – because people are more accepting that society now is more multicultural. But it does mean… And it’s interesting you say about kind of feeling welcome, and as Femi was talking I was thinking, yeah, I remember starting somewhere new and kind of sitting on my own feeling a little bit – grrr – out of it. Then I open my mouth and people hear a Mancunian accent and they’ll think, oh OK, someone who’s slightly from up north. Then we have a connection there, but it takes longer because people think, oh, what are you doing here?
And I think particularly over my career when I’ve sat on the advisory boards and things like that – you know, this is very senior people who usually would be middle-aged people, most of them would be white, especially for academic things – and then I’d be sitting there and people… You can see people looking at you, thinking, “What’s she doing here?” They didn’t understand what I was doing there.
I remember going to a conference, and I was actually presenting at the conference and then I was presenting a poster afterwards. And I’d written this paper on something, and so I was just standing by the poster about the paper. Someone comes along very excitedly: “Oh, I’m looking for Dr Smith, blah blah, blah, because I’ve read this paper and…” I said, “That’s me.” The disappointment on their face! [Laughter.] They were so disappointed. They were just speechless and then left. And it gave them a bit of… Because they just… You know, in their head, Dr Smith really was not me. I don’t know who Dr Smith was in their head.
But that thing of belonging, there’s always trying to find the place that you fit. And actually, the fact is sometimes you have to say, well you know what, I don’t fit here. I’m going to go somewhere else where it’s easy for me to be. Some people are better at carving out a niche for themselves.
But then the other side of that is we do have to practise being welcoming. And you’re absolutely right, Femi: actually, there is something about the culture of how you welcome people. And maybe… And that goes back to that thing of how do you overcome people’s unconscious bias? And maybe what we need to do is to just put in some structures and say, “This is the kind of thing that you do.” So I know that places like Devon do this pretty well. “This is what you do when you have new trainees, new people, new staff, whatever: whether they’re from overseas or not, you should have someone who’s their buddy who comes and welcomes them, who shakes their hand, introduces them to everybody, takes them around and says hello to everyone. You do invite them to dinner or tea or…” All those things. And you have to write it down. Because some of us don’t know what to do, actually don’t know how to make people feel comfortable.
If someone says, “If you don’t mind, I’d rather not come”, then fine. But at least – and even if it feels a little bit artificial – at least it’s been done and it gives people the opportunity to find someone who they may have something in common with. Because you don’t know that… If you’re judging people based on their accent or the colour of their skin, then you might never get beyond that to know what kind of person they are and what kind of doctor they might be, and what kind of colleague they could be. You know, it’s amazing when you sit down with people and you find out all the different things that they’ve done. It’s just so interesting. You would never know.
FO: Very true.
SM: And you’ve taken us nicely onto the wider scheme of things, beyond the topic we’re discussing – about just being curious about each other’s differences, I guess, and conversations, because we can learn so much from each other. Because if that’s there, then I guess culture change would be much easier. So that was my takeaway from that.
And with regard to acculturation and sort of belonging, I think your story you narrated, Dr Smith, that complements really well with the immigrant story that we were saying as well, in terms of it’s not just one situation that makes you feel like you’re not welcomed or belong; it can be very local. It can be due to other reasons as well.
The acculturation bit, I do find it very interesting that it’s like a journey. I often think about roundabouts; that’s something I had to get used to – most foreign doctors have to get used to – and it’s particularly the mini roundabouts that make me smile when I reflect about it, because there would be obviously… There’s a very clear culture of waiting and queuing, and I used to joke when I did IMG inductions that it’s something we have to unlearn when we change cultures, because back where we grew up, if you let everybody pass, you’ll never get where you’re going to. So it’s something to unlearn, so like at a mini roundabout where all the three cars are at a standstill, I joke that that’s when the Indian driver in me sort of comes up and I go, because everyone else would be waiting.
So, I guess there’s ups and downs and it’s a dynamic process over time that’s wonderful. And I wondered, Dr Smith, if you wanted to add anything about the College’s Equality Action Plan, which you’ve had quite a big role to play in? I’m aware… I did see the report, which was really comprehensive and promising about actual changes and recommendations.
SS: So, the action plan actually focuses on I suppose three areas. There are areas for the College and what the College has to do as an employer for its staff. There are areas for what the College might be able to do in terms of influencing mental health services, but also how the College can support and influence its members in terms of the curriculum or ongoing learning in terms of CPD [continuing professional development], how to support its members in terms of, actually, things like tackling racism in the workplace, which is… So, when you look at the action plan, there are a number of recommendations, and in fact as we’re going through those recommendations, they’re leading on to other bits of work. So the tackling racism in the workplace is one of those things that’s come about as a result of looking at the recommendations in the Equality Action Plan.
The curriculum stuff is particularly important because there’s a recognition that the curriculum –especially, and this is more… Sometimes people berate the College and say how come we didn’t do this before? And actually the College is like everywhere else. There’s been a lot of learning and understanding, especially over the past year and a half or couple of years. And so, you know, give us a break! The College actually had… You know, Wendy Burn started this when she was still President. In 2018 she said, let’s put out a statement about racism. That was even before the rest of the world really understood that things were pretty dire.
So the College is saying now, this is a work in progress and we’re trying and we are really trying to make an effort. As a result of the Equality Action Plan, we’re now developing a network of equality champions – people from all around the country at different stages of training (consultants, trainees), and also all linked to the faculties and their divisions – all of whom are interested in trying to improve equity across the board for psychiatrists and staff in mental health services, but also mental health services generally. We had our first meeting yesterday, which was great. And what we’re going to be doing is just trying to spread the word, raise understanding, make sure that there’s an evidence-based approach to things – all with a certain amount of humility. And curiosity, actually; you mentioned curiosity. Because if you don’t… If you’re not interested, what are you doing being a doctor? But certainly what are you doing being a psychiatrist? I have to say, if you’re not interested in other people… You’ve got to be interested in people to do this job, I think.
But it’s about recognising that… You know, we’re all learning all the time, especially in this area, and being able to be open and honest that we don’t know everything and that we are going to get things a bit wrong…
I think Femi right at the beginning mentioned something. Femi, you touched on something about, you know, it was when we were talking about battles, I think, and there are sometimes people who are alert to everything and it means that you can shut down debate and shut down conversation. And one of the things that – particularly with an area like this, which is so, so very personal and can be incredibly painful and overwhelming – everybody has to agree that you’ve got to give people some leeway, because if you… You’re not going to know the answers, and to get to know the answers, you have to ask the questions. To ask the questions, you have to admit that I don’t quite know what the issue is here, or I don’t quite know what that term means. I don’t really… How am I meant to say this name? What does it mean when people do this? Why do you do that in your culture? You know, you have to be able to ask those questions, and you’re not going to ask the questions if you think what you’re going to get back is an angry vituperative response, because “Why don’t you know it? You should know it! Go away and read it yourself!” Which is what happens a lot. And I think that in that sense we need to be perhaps kind to each other.
And the Equality Action Plan lends itself to that, actually. It’s saying, these are recommendations to begin with, and we are trying to use these to help change the structure of things. And if you change the structure of how we deliver care and how we treat each other, then you will change something about the culture of how you treat people. To begin with it might need some prescriptive stuff – but it will gradually become as standard, and this is just our usual practice and how we do things. And in that sense, it will be easier for people and there’ll be more equity across the board.
SM: Thank you, Dr Smith. That does sound very promising indeed, and things are definitely moving in the right direction. During my PTC time as well I did recall several positive experiences where feedback was given. For example, a white trainee had given feedback about the role players who were assigned during the CASC [Clinical Assessment of Skills and Competencies] examination and how the angry or unwell violent patients were black role players, where there were plenty of white role players, and just sort of challenged that; and that feedback was taken on board to be looked into. And so I guess even small things that are raised – people being allies in small ways, even – can go quite a long way in making change.
So in the interest of time, Professor Oyebode, I wondered if you had any final thoughts on things we’ve discussed today. Any poetry to inspire us with? Anything at all to conclude?
FO: Thank you very much. I’m not sure about poetry. I was doing some poetry reading – Black History Month poetry reading – just yesterday, but I haven’t got them next to me because I’ve cleared all the books and they’re just behind me. But yes, it’s been wonderful talking to both of you, Shevonne and Shubulade.
It’s… We discover things ourselves, don’t we? We think we know all these things, but just listening to one another talk, we discover that we’ve got a commonality of experience and that we also have slight differences of opinions about how these things are, which tells us that there’s room for conversation, tells us that conversations of this kind are very, very rewarding indeed. And maybe we should find a way on the College platform, in the context of a conference or Congress – because it takes a lot of courage to do what we’ve just done this afternoon – but having a platform where two or three people can talk about these matters without fear that they’re going to say the wrong thing or something of that sort. And the audience will then learn quite a lot about the things that we’ve experienced that we very, very rarely share with anybody else outside of our families because we’re afraid that people will say or think that we’re complaining, or that we’re accusing others and things of that sort. Yet that’s not the purpose. The purpose is not to accuse anybody. It’s just to help other human beings know some of the things that we experience in this country which ought not to be happening.
SM: That’s a wonderful suggestion, Professor, and I do hope that happens in terms of the platform and sort of more generally having that space – what they refer to as psychologically safe space – because we’re all learning, as we were discussing earlier, and everyone makes mistakes and sometimes things are not intentional. But as long as conversations happen and curiosity is there, I guess change can happen.
SS: There was just something I wanted to add actually, and it’s probably quite a serious point, so I should have said it earlier. But it is this: that I worry sometimes that people might feel – and this isn’t just white colleagues but black and brown colleagues as well – that people might feel that (and I’ve heard people say this) talking about this stuff and everything else, and trying to improve equality issues, it’s somehow a bit of a screen for taking over. And there’s a fear; people have a fear that, “Hold on a minute! We’re going to be replaced!” It’s a bit like Invasion of the Body Snatchers or something. You know, there’s this big fear that everybody’s going to be taken over, that there’s going to be this nightmarish situation whereby you’re not allowed to speak your mind, you’ve got to conform to a certain kind of ideal, et cetera.
And actually, I want to be absolutely clear to people: the fact is that if you are brown or black, you are in a minority in the country, and that’s not going to change, actually. That’s not going to change ever, probably; it’s always going to be the case. And all people are asking for is to be treated with the same level of dignity and respect that allows them to achieve their potential in life that, if you are white, you get as standard. And that’s all it is.
And I think that needs to be said because I think there is a fear that somehow this is about getting something more than people who are white get – and it’s not. It really isn’t. This is just about saying that there are people who aren’t able to achieve their potential, not because they’re not brilliant at what they do, not because they’re not clever, not because they’re not able; it’s just because of the colour of their skin.
SM: That’s a lovely note to end on, Dr Smith. Thank you so much.
I’m so delighted to have had you both join, and I do agree it is a very difficult topic to talk about. I won’t deny that I was really nervous to talk about it and even just to facilitate, even though I knew you both would be sharing all the wisdom. I hope our listeners enjoy this too and I hope it encourages colleagues to be more curious, want to understand the lived experience of our colleagues of ethnic minorities, want to be allies – so that eventually we can level the playing field for everyone.
We do have more resources and reading links, which will be added to the College website. We do hope you will also come back to listen to the other episodes to do with healthcare professionals’ well-being.
And thank you so much to our guests today, Professor Femi Oyebode and Dr Shubulade Smith. I should also ask, like you mentioned earlier, whether I did pronounce your names right to end with.
FO: You did.
SS: Yeah, you did. Thank you very much indeed.
SM: Thank you so much.