Mark Moran [00:00:03] Hello and welcome to TGen Talks. I'm Mark Moran. Recent events and social protest have prompted increased dialog, and rightly so, on the topic of diversity, equity and inclusion in America. It's a big topic that covers multiple segments of society. But this edition of TGen Talks will focus on how diversity relates to the fields of science and medicine. Our guest is Dr. Joseph Mikhael, professor of Applied Cancer Research and drug discovery at TGen and Chief Medical Officer of the International Myeloma Foundation, or IMF, and a counselor on the Executive Committee of the American Society of Hematology. Dr. Mikhael joins us today to share his personal story and insights into how we all can become better at embracing and understanding differences that make us unique and the value inherent in assessing our own thoughts and beliefs. Dr. Mikhael, welcome. Thanks for being here.
Dr. Joseph Mikhael [00:01:00] Thanks very much, Marcus. Great to be with you.
Mark Moran [00:01:02] As a person of color, you bring unique perspective from both a personal and professional standpoint to the dialog around diversity, equity and inclusion in our society. How have your upbringing and your beliefs and your experiences shaped your career and how do you think they're shaping your future?
Dr. Joseph Mikhael [00:01:19] Thanks so much for that question. No, I think it really captures the notion that this isn't just a topic that affects one aspect of anyone's life. It really is quite pervasive. I often say it's as personal as professional. Some ways, unfortunately, it's become political, but it is really important for us to think this through. And I appreciate the opportunity to spend some time discussing it with you. I may not always be the best one to answer all of these questions, but my personal experience, I think, has really facilitated my approach to my work now and hopefully indeed in the future. My experience was such that, you know, my parents came from Africa. I was born here in North America, in Canada. But even from a young age, I was very sensitized to this issue through my parents, primarily because they were Christians. They were living in Egypt, which was primarily a Muslim country. And just by virtue of having a Christian name, my father was told that he could not do certain things in the medical career. He worked very hard and went to medical school, became a surgeon, but he could only be a certain type of surgeon because Christians were only allowed a very narrow specter. Similarly, my mother went to medical school with 200 students in the class, of which only three were women. And I think those two things, even just hearing about them and trying to understand that, made me appreciate that people get treated differently for reasons that initially don't really make sense. And I've always been very cautious through that to recognize the importance of religious diversity, of gender diversity and indeed of color being a person of color. I try to not look at anyone else with any kind of color. And and that was so ingrained in me from the very start in my personal life that I think that's what ultimately influences your professional life. When people understand this issue on a personal level, then like issues of honesty or integrity, they then pervade your professional life. And so in my profession, I've always been sensitive to that. I always have wanted to include this notion and what I do. And in many ways, I think it's one of the reasons why I end up traveling around the world so much, of course, before COVID, because I have such an interest in understanding different backgrounds and perspectives.
Mark Moran [00:03:38] You were raised in Canada. Are there differences in cultural perspectives when it comes to diversity between the U.S. and our neighbors to the north?
Dr. Joseph Mikhael [00:03:46] You know, in many ways our cultures are very similar, but in some ways there are some significant differences and this may be one of them. I don't want to overgeneralize because of course, there are vast differences within a country. But I like to give this example. Canada often speaks of itself as a mosaic. So people have come from so many other countries. And when they create that beautiful pattern of Canada, they retain their own individuality. Someone thinks of themselves as a Japanese Canadian or as a a French Canadian if they came from France. Of course, there's French within the country as well. And so I contrast that to the American melting pot where you come with your diversity, but sort of everybody blends into about the same thing. I'm not saying the melting pot is a bad idea. It's a beautiful concept of people merging together. I would never wanted to deny that. But that retain difference is a little bit there. And I think there was a bit of a different approach. Having lived in Toronto, the most metropolitan city in the world, it was like walking through the United Nations in my 10 minute walk to the hospital every day because we saw that. So it was a little bit different for me when I came to different parts here in the U.S. where there's a bit more of a monochromatic expression within individuals. But that doesn't mean, of course, that people can't be sensitive to the issue.
Mark Moran [00:05:14] Diversity and equity in the workplace for broad topics. To be sure, they can include lots of factors. What does discrimination look like in the sciences? And why do you think it exists?
Dr. Joseph Mikhael [00:05:25] Well, I think we are coming to appreciate as a society that these issues affect so many different avenues of life and science and medicine are not unique in that way that they are very much affected. Some of it we understand, and the principles of both conscious and unconscious bias, particular unconscious bias where people don't think in medicine. We say, if I said to someone, the spouse of our neurosurgeon is walking down the street, someone immediately thinks that the neurosurgeon must be a man and so the spouse must be a woman. And we aren't doing it so deliberately to be malicious, but we just haven't appreciated that aspect of it. So I think the whole setup initially, if you will, has the potential of being non-inclusive and non diverse, then specifically access to training is a very big issue where we find that even if in a diverse country like the US, when we look at the number of individuals, whether they be of color, for example, that are accepted to and go through medical school really is much smaller than it should be if it reflects society. We know that in medicine we want that feel to represent the true reality of our country. And so that becomes an issue when there are fewer individuals from various backgrounds that even enter into med school and then even those who are in medicine or of the other sciences. We've known and seen that it is more difficult for individuals of color. And in particular, it's also difficult for women to have the same path to a promotion that we might see with their Caucasian or male counterparts where the system has been built to facilitate a certain method of advancement and promotion. And that may not always be reflective of that diversity. And so we have consistently seen this that has ultimately resulted in the fact that in many high end academic institutions, at the highest end of leadership, at the level of the dean or professor level, that we have an underrepresentation of women and underrepresentation of of individuals of color. And that hasn't always been a deliberate process, but it does make us question the whole system and how it functions. And also, hopefully through conversations like this, sensitizes people to that to make sure that we don't add additional barriers that can be removed and that we can remove current barriers to ensure that promotion is based on scientific merit, mean that that's what we believe in science, isn't it? That we want to promote that scientific method of equity and of fairness and so we should reflect that in our own community.
Mark Moran [00:08:14] Racial and social discrimination shouldn't be tolerated, but in certain situations it still is due to hierarchies or things that seem to be ingrained in the workplace culture, either through seniority or influence or other things unspoken. Is it a problem in the sciences? And if so, how do we overcome it?
Dr. Joseph Mikhael [00:08:31] It is a problem. I think we've seen, as I've just mentioned, that the sheer lack of individuals of color in certain areas of science. And unfortunately, this does reflect the society's allowance of individuals to go into that. But even thinking very pragmatically, you know, I had the privilege of being part of a study that we evaluated when we were at an academic institution at what we call grand rounds, where really the sort of the top lecture of the week was given once a week and a large academic institution and without, of course, informing the speakers. In the end, those who were introducing the speakers, we objectively noted how speakers were introduced and we noted a significant difference, that if a female speaker was speaking and her introducer was a male versus a female introducer, that male introducers are more likely to introduce a female by her first name and not by her title as doctor, and are more likely to introduce men as Dr. Smith, for example. And so that's something where it's partly an issue of unconscious bias, but it is a notion of discrimination that you're viewing a female physician differently than a male physician. Perhaps you view them as less scientific or more personal as opposed to more scientific and professional as we as we should. And that's just one tiny example. And we see, sadly, the same reflection in individuals of color and individuals of diverse backgrounds. Partly because people aren't as familiar with them. And I think this goes back to one of the points we made before for how important it is even with our own personal lives to understand that diversity. To look at your own friend group in your own area and think, do I know people of different backgrounds? Do I take the time to understand that there isn't one way to cook this meal and one way to live this life and one way to think? And those kinds of aspects need to pervade more of our scientific community for it to ultimately, hopefully have a better outcome for all of us.
Mark Moran [00:10:45] Our guest today on TGen Talks is Dr. Joseph Mikhael, professor of Applied Cancer Research and drug discovery at TGen. He's also chief medical officer of the International Myeloma Foundation and a counselor on the executive committee of the American Society of Hematology. Dr. Mikhael, if and when people do speak up about problems of diversity or slights of any kind in the workplace, do you think there's a fear of being labeled a troublemaker or not wanting to rock the boat, so to speak, or even fear of repercussions for raising those concerns?
Dr. Joseph Mikhael [00:11:17] I think historically we have had that kind of, you know, very harsh approach to anyone raising a concern and partly in science, because we think of the scientific method. But yet we should also be thinking that we do question everything. And and I think what has happened in medicine and science in particular is that we've become a bit rigid in our thinking and haven't allowed ourselves. You know, I can say if I'm going to give a talk to a group of doctors and say to them, all right. Let me give a talk to you on how to communicate and get a lot of eyes-rolling. People saying, wow, hey, maybe I'm not the best communicator, but I really know this sort of I know better than you are. And sometimes in medicine and even in broader science, we have this. We're smarter than others. And so we don't really need to learn more. We've already you know, I have more degrees than a thermometer. I don't need to learn anymore. But the reality is this issue is uncovering that. We do need to learn. We do need to create an environment that when someone says, wait a minute, is this inappropriate that we have six speakers at our conference and all six are men? Is it inappropriate, that we live in a diverse society, and yet we are not reflecting that diversity in our leadership and in our activities? And so although historically there has, I think, been that backlash, and I'm not pretending it hasn't gone. I think there's issue right now is raising an awareness that allows us to say this is a concern to me and perhaps we should be careful. And we should note that female physicians should be addressed appropriately in her introduction. After that study that I mentioned, we wrote to some of the major societies in North America that host these massive meetings. And thankfully, now every introducer has explained this issue and is told to introduce each of their speakers in a systematic way. And hopefully that will ultimately reduce some of this disparity that we see.
Mark Moran [00:13:16] You mentioned unconscious bias briefly a few minutes ago. But let's elaborate on that just a bit. How do you think unconscious bias affects decision making within all levels of the scientific community? And are there any potential positives with it?
Dr. Joseph Mikhael [00:13:30] I think the positive element to it is that we realize that is a problem. I think that the way we're going to overcome this is, you know, I keep it very simple. I mean, raising awareness of this issue is clearly happening. You can't watch the news. You can't listen to radio or have a conversation at the at the virtual or real water cooler and not realize that this issue is there. So to me, that step number one.
Dr. Joseph Mikhael [00:13:56] Step number two is genuinely to listen. And what happens is people want to speak right away instead of listening to that other side of the story, to listen to that other perspective, to understand. I've had the privilege of leading a major initiative for the cancer that I treat in multiple myeloma, which affects African-Americans twice as frequently as Caucasians, and spending these last couple of years listening very carefully to individuals from the Black Congressional Caucus and the National Medical Association. The Black Nurses Association has given me a perspective, even though I've been a myeloma specialist for 20 years, has given me perspective I never fully appreciated before. So listening is step two.
Dr. Joseph Mikhael [00:14:39] Step three then is to even to study it more. And that's what we do as science. We need to look like that study that I mentioned of of gender inequity with introductions. We need to look at this objectively and understand it. And then perhaps most importantly, is apply it is to do something about it. We need to recognize that this is a systemic problem within science and we can address it like we address other problems. We're trying to cure cancer and we're trying to, you know, do all these marvelous things. We have to look internally. I study these issues and clearly apply them.
Mark Moran [00:15:10] Inequities certainly exist in most workplaces today. In fact, it's something TGen is tackling. Do you think inequities within the scientific community actually extend into and affect patients we're trying to help? We've heard that COVID-19 has had a proportionally larger impact on communities of color than on nonminority communities, for example.
Dr. Joseph Mikhael [00:15:31] Well, clearly affects patients. I think at times we think that the differences may be purely biological. And in some cases that is true in my mentioned in multiple myeloma. We know that it not only affects African-Americans twice as commonly, but their age of diagnosis is significantly younger than Caucasians. So. So on a scientific level, we might initially say, OK, well, there's a biological difference and let's study that. But we've kind of have to come to appreciate it so much more than a biological issue. It has very much to do with access to care. With, as we've mentioned before, unconscious bias or discrimination, or why is it that African-Americans account for 20 percent of all myeloma patients, but only six percent of those who are on clinical trials? So why are clinical trials not available as overtly to the African-American community? Why is that? The some of the key standard treatments, the novel chemotherapies we use or the approach of autologous stem cell transplant is clearly offered significantly less to the African-American population and to the Hispanic population in this country. So these aren't just ethereal, theoretical concepts. This ultimately affects. So, again, not to make it all about my disease, multiple myeloma, but it's because what I know a little bit more that we have seen a doubling, if not tripling of the average survival of patients with this condition over the last decade. It's one of the cancers where we've seen tremendous success. But the degree of that success has unfortunately not been seen in the African-American and Hispanic populations. And so it begs us to ask the question why? And it's not just about biology as much to do with many of those other things.
Mark Moran [00:17:20] In terms of diversity and equity and inclusion, what issues should the larger scientific community be talking about that it's not?
[00:17:28] Thankfully, a lot of these these topics are being discussed now that have been almost taboo for the longest of time. But I do think that those very issues that you've mentioned, in particular the notion of unconscious bias because it is unconscious. But I must say, I think sometimes we focus a lot on unconscious bias and not really the conscious bias. Going back to the example of of my father, it was just an acceptable phenomenon that because he had a Christian name, he was not going to be allowed into certain things that that does happen in this country, that we do not just have unconscious. But there are clear conscious differences. And having those open and honest discussions and before trying to lay a blame game, trying to understand what those problems are. And I think we can lead as the medical and the scientific communities. We should be leaders in this. We should be the ones who have the opportunity to think this through and study it and present genuine solutions. But perhaps the last thing I would say about that is that it starts with the individual. It's one thing to have a policy and an approach. So it's one thing, for example, for me to tell that introducer, please use the title of the female physician, but that shouldn't have to be hard for them. There's something that starts in the heart of each of us as we look at this issue and not make it political. And even before it becomes professional, we make it personal and realize that these are individuals who are equal to us. These are individuals that we all we have so much more in common than we do. That differentiates us, you know, working at a genomics research institute. I can tell you that, you know, we think of the diversity of the genome, and yet so much of it is so similar that it is different and we have to be role models in embracing that ideology, or else we will constantly be fighting to unfortunately, the detriment of many.
Mark Moran [00:19:34] As we continue to pursue equity what steps have you found helpful toward educating others on this issue and how can teach and be an advocate?
Dr. Joseph Mikhael [00:19:42] The awareness issue is very important, which is happening now that we start discussing it. But I think people should look very objectively at things that they may not have perceived before, which is, for example, looking at your own network of friends. Not that you have to mandate that you have X percent of your friends that don't look or do look like you. But but do you have that personal experience? Do you look beyond your borders? Obviously, right now it's challenging in the times of COVID, but one of the blessings I have is I spend about a third of my time in the Third World trying to facilitate collaborations and research collaborations and access to drugs. When I spent time in these different countries and I see how different people function, that I'm always awed by the diversity and unity at the same time that food might taste so much different in a certain country and people look different and have a different lifestyle. You know, not everybody wakes up, gets in their SUV and drives to work in the morning and yet at the same time there's so much incredible unity that everybody wants to be loved and enjoy a good meal and a good laugh and and feel like they're part of something that is making a difference. And so I encourage people to to on that personal level, even before the professional level, to think that way. But then on a professional level, I do like to point things out and I like try to as much as I can be a role model and say as as Francis Collins from the NIH said, that he refuses to participate in "mandles" or man panels where I do the same in my professional career. If I'm invited, which I do on a regular basis, to give a talk often with a group of individuals, if there are three or more individuals and there isn't a woman on the panel, I will decline it. And all gently but firmly mentioned to the organizers that I think this is a deficiency. We have incredible women in our field and not just a male-female issue, but in other areas of diversity. Are we reflecting that in what we do? And sometimes going back to this notion of unconscious as people may not actually first realize that? Do they realize that their advertisement for this meeting only had the faces of white men on them? Right. I joke, called the GCM club the Great Comb Over Club, you know, to make light of a serious issue. But we have to rethink that and realize that those kinds of things promote an idea or a thinking that, well, it's only accessible to a certain group of individuals.
Mark Moran [00:22:15] In 2003, while delivering the Killam Lecture at the University of British Columbia, Dr Shirley Tilghman, at the time president of Princeton University, stated that "science will look increasingly anachronistic if women and minorities are not participants in the enterprise as other professions move successfully toward a goal of inclusiveness. Science will appear increasingly backward looking and will be less attractive to talented students of all types."
Dr. Joseph Mikhael [00:22:45] Remarkable statement by a remarkable individual and I think very influential in the way we should think about this issue.
Mark Moran [00:22:54] That was 17 years ago, 17 years later. Dr. Mikhael, does it still hold true today? And how far do you think we've come? What barriers still exist?
Dr. Joseph Mikhael [00:23:01] I think we've come a long way since 2003, but we've clearly not come a full way. And some of this will obviously take time. You know, it's remarkable to me that if we now look at the last decade in both Canada and the United States, because this address was in University British Columbia, in Canada, that both countries are now in their medical schools in total, have had more women in medicine than men. And now there's obviously a sort of a lifespan to that as as those individuals then move through their residency training and now fill positions. And we anticipate and hope that it should influence leadership with time. We've often called it the feminization of medicine that in many ways has been very good, that the rules about, you know, on call rules. And when I used to be a postgraduate dean and so we had these, you know, our rules about how many hours that residence could be on and their time off and so on was very much built on a model that no one would ever be pregnant, for example. And that was totally inappropriate. And so we've seen those changes. And similarly, we also understand particular in medicine, we have very clear evidence and has demonstrated this over and over again, that patients really want to connect to their physician and health care team and they can on multiple levels. But one of those areas that can be particularly helpful in minority populations are when their physician or their nurse practitioner or their nurse looks like them. And so to reflect that diversity within our medical training of all types of diversity, cultural, sexual, racial, it becomes very, very important. And so I'm I'm glad this statement was made because it was a bit of a stake in the ground saying we're going to go backwards if we don't move in this direction. And I'm thankful as I see medicine evolve in areas of science of all that we have moved in that direction, but we haven't moved far enough. And some of it relates to those continuing unconscious biases that I hope we can overcome through processes like we've discussed.
Mark Moran [00:25:11] Dr. Joseph Mikhael feels like we've just scratched the surface today, but we've covered some important ground nonetheless. The dialog will most certainly continue. Thanks for being with us today.
Dr. Joseph Mikhael [00:25:20] Thank you very much. It's a privilege to be here.
Mark Moran [00:25:22] Dr. Joseph Mikhael, professor of Applied Cancer Research and drug discovery at TGen. He's also chief medical officer of the International Myeloma Foundation and a counselor on the executive committee of the American Society of Hematology. You can hear this and other editions of TGen Talks at Tgen.org/tgentalk. TGen is an affiliate of City of Hope. Thanks for listening to TGen Talks. I'm Mark Moran.