#OperationEqualAccess - Dr Mariana Berho interview

Achieving diversity, equity and inclusion for the healthcare professionals: How to?

ZG MBerhoDr Mariana Berho, Chairman of the Department of Pathology and Laboratory Services, Chief of Staff, at Cleveland Clinic Weston shares with the ESCP audience her experiences in achieving diversity, equity and inclusion in the healthcare sector.

Zoe Garoufalia (ZG): Dr Berho thank you very much for agreeing to this interview. As a leading female physician from Argentina, could please share with the ESCP audience your experiences through training and challenges you experienced?

Mariana Berho (MB): The first five years in the US were very challenging, especially, the first year. Looking back, I, perhaps underestimated how difficult the insertion in the American society would be. My command of the English language was marginal and I would get extremely anxious when I was addressed at a conference or asked a question. Firstly, not unfrequently, I did not quite understand the question due to my language limitations and, when I did, many times, I would not quite find the right words to answer appropriately. People around me where kind and empathetic, yet, the first year I was home sick. Furthermore, during my first year of residency in West Virginia, I went to Argentina for a visit and I seriously considered to not return to the US. Thankfully, my good judgement prevailed, and here I am. I feel very fortunate to have developed the necessary resilience to endure those years and I am extremely grateful for the opportunity this country has given me

ZG: The American College of Surgeons ran a series on surgeons’ well-being. As stated 'ACS recognizes the need to foster well-being, resilience, and work-life integration for all surgeons, regardless of their career stage. Fostering the growth of both the surgical expertise and the person as a whole is paramount'. As the Chief of Staff at CCF, how do you advise colleagues and trainees to accomplish this? How could a. healthcare organisations and b. physicians, work towards achieving this goal?

MB: Work-life balance is very important, however, sometimes the term is misused or, perhaps, overused. The threshold to achieve balance between work and life is different for every individual, in other words, what may lead to burnout in one person may be different for other people. Surgery is a very demanding specialty, it may take many years and many hours of the day to achieve proficiency and competency. I feel, self-awareness is critical when choosing a specialty in the medical field. We need to ask ourselves difficult questions, for example, am I willing to invest the time and the effort that the life of a surgeon requires?. Having said that medical institutions have a responsibility to provide the necessary resources to build and maintain well-being for its surgeons. The work environment, both physically and psychologically has a significant impact on our well- being. Chaotic working conditions, inadequate instrumentation, lack of nursing or clerical support can lead to feeling psychological unsafe. Freedom to speak up, to express concerns without the fear of retaliation is fundamental for our emotional well-being. It is the institution obligation to grant an environment conducive to professional fulfilment. Programs that encourage physical wellness, including, free or discounted access to practice physical exercise are sometimes offered by medical institutions. Psychological and emotional support provided by health care professionals or peers are becoming popular in large institutions with high case complexity. Support for mothers of young children, in the form of association with well-established child care organizations has been very well received by our female physicians. I would like to remark, that, although institutions need to facilitate the well-being or their employees, we, ourselves hold the ultimate responsibility of understand our body and mind, recognize our triggers and making the decision to stop when we are getting to the breaking point. Nobody else can do it for us

ZG: In health institutes the many challenges faced and the occupational stress often lead to aggressions and conflicts. Managing them is not always an easy task. What is your recipe for mitigation? What would you advise young surgeons and other healthcare professionals when faced with such issues?

MB: Conflict does not have to be harmful, in many occasions, conflict gives us an opportunity to reflect about our positions, interests and values. Framing conflict as a win-lose proposition is almost never the best choice. When involved in a conflict, we could start by practicing a mental exercise and formulating a few questions in our minds: What is the conflict about (the issue)?, what are the facts (what happened)?, how am I feeling about the situation (emotions)? and, what is my goal, in other words, what is my desired endpoint for this conflict. These simple questions prevents us from getting tangled in conversations with the other party that may not be relevant to the conflict per se. Understanding that being right is not the most important thing in conflict, is a very difficult concept for us humans to grasp, however, again, most of the times, finding a resolution for the conflict is much more relevant that having “the truth”. Few practical tips that work for me when immersed in conflict: 1.don’t assume intentions from the other party, as most of the times you will be wrong!, contrary to what we believe, we cannot read minds; 2. stay away from blame, it immediately creates an aura of defensiveness that will hamper an honest conversation, 3. listen carefully before you answer, remember…words matter, and, finally, the most difficult one…try to NOT judge. Ah, also, don’t feel that you have to accept every invitation that you get from people to participate in a conflict, choose your battles

ZG: As Chief of Staff in CCF, how tangible is achieving diversity, equity and inclusion amongst the many staff members? It is a very broad question, but I would love to hear your experience on how this could be achieved.

MB: There continues to be a lot of talk about diversity and inclusion, and often, these words are used loosely or almost interchangeable. Put out simply, diversity is about our differences, including gender, age, race, religion and socio-economic status among other personal characteristics. Having a diverse medical staff is clearly not sufficient, we need inclusion, and this means people with different identities feel they are valued within a team or a workplace. In this regards words alone are not enough and concrete action is necessary. Expanding diversity and stimulating inclusion requires intentionality, it does not grow organically. A conscious effort is necessary to broaden the diversity of the staff. It starts at the time of posting a position and the job description. Clear language that conveys the commitment of an Institution to diversity and inclusion is critical. Characteristics of a job description that will stimulate the application of minority groups includes words like “flexibility of schedule”, both “full or part time employment will be considered”, “LGTB members are encouraged to apply”. It is, of course, important that actions match words, periodic reviews of the composition of the medical staff allow us to keep the pulse on the efforts on diversity and inclusion.

ZG: How are race, gender, qualifications, and merits weighed in the complexed equation of diversity?

MB: It is tempting to assume and believe that merit should be the only attribute that needs to be taken into account to decide hiring, promotion and compensation. It is important to keep in mind that merit is very much related to the opportunity each individual has had through their lives. This concept reflects exactly the difference between equity and equality. Each of us have a different set of circumstances and allocating resources according to that unique context is what equality emphasizes and what the society as a whole is responsible for. In other words, merit can be valuable in decision making only when there has been equal opportunity

ZG: Have you ever witnessed discrimination of any kind in the workplace? And if yes, how was this managed?

MB: I have, mostly in the form of unconscious bias. Explicit discrimination is rare, though not completely gone. Unconscious bias is based on incorporated stereotypes, many related to women and men traditional roles. When I started my residency, 25 years ago, women were discouraged from entering into a surgical training program, as this specialty was traditionally thought to fit the lifestyles of males. I think that from the gender perspective we have made a lot of progress, however, we are clearly not there yet. An example of covered bias are those circumstances in which a leadership position is posted and all search committee members are white males. There is plenty of evidence that non-diverse decision makers lead to non-diverse decisions which result in a loss of creativity and optimal outcomes. One of the biggest challenges that we face with confronting unconscious bias is exactly that, these biases are unconscious and therefore the involved people don’t realize they are exercising bias. Bringing awareness to the conscious level can be extremely hard and we are often challenged by denial, disarming bias is not an event, it is a long process. Because of the challenges that minorities face every day, women and other minorities are encouraged to recruit “allies”, there is nothing more powerful than men advocating for women

ZG: How can the surgical community, young and senior, contribute in order to promote diversity, equity and inclusion?

MB: Cultural competence and proficiency are very important, being curious about people that do not look like us is helpful. Let’s concentrate on our differences to understand diversity and on similarities to promote inclusion.

ZG: This was extremely helpful and eye-opening. Thank you very much for your time and sharing your insights!


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