Introduction

The unjust murders within the USA's black community, notably that of George Floyd, sparked global outrage and determination for justice. Mr Floyd was murdered by a white police officer in the US city of Minneapolis on 25 May, 2020.1 Social media became flooded with support for the Black Lives Matter movement, which aims to shed light on the racism and discrimination experienced by the black community. Racial inequality was finally heading towards receiving the attention it deserved. Individuals worldwide were educated on the issue and inspired to contribute to change. Amongst such individuals were a group of students from the University of Birmingham Dental School. This article serves as an account of our work, but more importantly aims to educate the reader on racism and discrimination in the dental workplace.

Background

On 31 May, 2020, the Birmingham University Dental Student Society (BUDSS) released a social media statement expressing their support for the Black Lives Matter movement. The statement also outlined how individuals can deal with discrimination in a clinical setting, adapted from the British Medical Association's Racism Charter in Figure 1.2 The post had a fantastic response; it was seen by 19,488 individuals, and reposted by 32 dental and medical schools on their respective social media outlets.3

Fig. 1
figure 1

BUDSS' social media statement

Full size image

On the back of the social media post, the Birmingham School of Dentistry's Equality, Diversity, and Inclusivity (EDI) Committee was formed. The team comprises past and present students and senior members of staff, united by a shared determination for change. The EDI group investigated experiences of discrimination within the hospital by distributing an informal survey to gather data on the issue. The data highlighted a clear need and desire for staff and student EDI training. Thus, the main efforts of our committee turned towards running workshops on racism and discrimination.

Our work

Our workshops, delivered to students and staff, aimed to educate, and empower the audience in tackling discriminatory encounters. The following may serve as an outline for those wishing to carry out workshops themselves.

Outline of the EDI workshop

Step by Step: Equality, Diversity, Inclusivity, Training Workshop

  1. 1.

    Pre-workshop survey

    • Have you experienced any forms of discrimination?

    • On a scale of 1-5 how comfortable do you feel handling a discriminatory encounter?

    • Do you think your practice/ hospital has made its complaints procedures and policies on discrimination clear?

    • Do you think there is a need for EDI training?

  1. 2.

    Definitions

    • Racism: Prejudice, discrimination or antagonism by an individual, community or institution against a person or people based on their membership of a particular race or ethnic group, typically one that is a minority or marginalised. e.g. Racial slur.4

    • Microaggressions: Everyday slights, indignities, put-downs and insults that members of marginalised groups experience in their day-to-day interactions with individuals who are often unaware of what they have engaged in an offensive or demeaning way. e.g. 'Where are you from? No, where are you really from?'5

    • Unconscious bias: Social stereotypes about certain groups of people that individuals form outside of their own conscious awareness. e.g. Only giving students of a certain race or religion extra-curricular opportunities.6

    • Stereotypes: Oversimplified ideas about groups of people and biased thoughts based on flawed assumptions about a group of people. e.g. Assuming that you are unable to extract teeth from all of your Black patients because of their increased bone density and instead referring them to your local OMFS department.7

There is an opportunity here to discuss more definitions and the effects of different forms of discrimination on individuals from marginalised communities.

  1. 3.

    Scenarios

    • Opportunity to go through case-based scenarios and have group-based discussions regarding the experience of discrimination and management.

  1. 4.

    Post-workshop survey

    • Do you understand the terminology regarding the different forms of discrimination discussed today?

    • How confident do you feel in your ability to identify a microaggression?

    • Following the workshop today how prepared do you feel challenging discriminatory encounters in the clinical environment?

    • Did you find the workshop insightful? If no, please state why.

    • How could this session be improved in the future?

Answers from this survey were utilised in adapting the workshop for the future.

Of particular focus in our workshops was the topic of 'microaggressions'. The term 'microaggression' describes subtle, and often unintentional, discrimination against a member of a minority group. It is less easily identified compared to overt racism, but the effect on those at the receiving end cannot be underestimated. We looked at four scenarios detailing discriminatory encounters, with suggested management for each. Scenarios A and D cover examples of microaggressions. The authors recommend the reader to give thought to the scenarios and as to whether they would be confident in identifying and managing such encounters.

Discriminatory Based Scenarios

Scenario A

Patient X is a regular attendee at the Community Dental Centre, however it is the first time that Student Y, a South Asian fourth year, is treating patient X. The patient X states: 'your English is so good considering it isn't your first language.' Student Y laughs off the comment and notifies their supervisor after the appointment. The supervisor regards the comment as a compliment and says, 'I'm pretty sure the patient didn't mean anything by it.'

What went wrong?

  • Patient presumes student is from a different country based on skin colour

  • Student made to feel uncomfortable

  • Supervisor should not dismiss the experience of the student

How could this have been managed?

  • If student felt comfortable enough to say to patient: 'English is my first language.'

  • More support from supervisor: 'I'm sorry this has happened, would you like me to speak to the patient?'

Scenario B

Dentist sees Patient X for a new patient exam. The nurse leaves the room. Patient X turns to the dentist and says: 'Please can I have a white nurse?'

What's the problem?

  • Patient is overtly racist

How can this be managed?

  • Zero tolerance policy for racism: 'May I ask why you would prefer a white nurse?'

  • 'All of our nurses are equally well trained, if you aren't happy being treated by any member of our team based off of skin colour, you will have to seek treatment elsewhere.'

Scenario C

Patient X presents looking dishevelled at a treatment planning appointment. Dentist Y provides patient X with treatment options for anterior tooth replacement. Patient X queries why the option of an implant wasn't mentioned. Dentist Y responds: 'That would be available privately, which I had assumed was out of your price range.'

What's the problem?

  • Dentist has made an assumption based on appearance

  • Valid consent cannot be obtained without all treatment options being presented

What can you take from this?

  • Never make assumptions based on appearance

  • Try to identify and address your own unconscious biases

Scenario D

You have just completed root canal treatment and there are lots of instruments spread across your surgery. The patient looks around and remarks: 'It looks like a bomb went off in here!'

You notice your nurse looks visibly upset, as you know they are a refugee of war.

You reply: 'I get what you are trying to say, however please be considerate of what you are saying.' The patient responds: 'I'm sorry, what was wrong with what I said?'

You reply: 'You should be wary when making references to bombs, as you never know if those around you have been affected by war and may take offence.'

Positives

  • Recognition of nurse's expressions

  • Proportionate and sensitive management

What you can take from this

  • It is easy to dismiss comments such as this as often the intention is not to offend, however, by addressing this you are not only supporting your colleague but also educating the patient.

In addition to running workshops, the EDI group at Birmingham Dental School have been leaving their mark in other ways. The committee identified a need to improve the reporting system for discriminatory encounters within the dental hospital. We pushed for a reformed, streamlined policy, empowering staff and students to confidently report inappropriate behaviours that present in the clinical environment.

The EDI group has also been developing a 'safe-word' that is due to be implemented hospital-wide. The role of this word is to discreetly alert colleagues that a peer is in need of aid. The colleague will then assess the situation and respond appropriately, which may involve removing their peer from the situation or alerting security services, for example.

Lastly, the EDI group is in the process of replacing the current 'three-strike policy' for a 'one-strike policy'. At present, patients are given a verbal and written warning for inappropriate behaviour prior to discharge. We believe that staff and students should not be expected to tolerate such behaviour, and therefore a zero-tolerance policy should be adopted. This portrays a clear message that inappropriate behaviour of any nature, including racism and microaggression, will not be tolerated within Birmingham Dental Hospital.

Examples of suitable and unsuitable safe words

Example scenario: 'Patient makes a dental team member uncomfortable, and tensions could escalate at any moment.'

Appropriate safe-word: orange mirror

'Please could you get me an orange mirror?'

  • Patient is unaware of safe-word

  • All other members of dental team are made aware and are able to respond appropriately. e.g. Bringing a senior dentist or practice manager in to the surgery

  • This item could be applied to all procedures and is not limited in use such as the use of a 'pink light cure' or an 'anterior bitewing holder'.

Inappropriate safe-word: Red prescription pad

'Please could you get me a red prescription pad?'

  • Patient is alerted to 'red' prescription pad, an alarming word which is likely to raise suspicions

  • Risk of patient escalating the situation further/ asking the individual what a red prescription pad is

  • Risk of endangering the individual who asked for help and further confrontation

  • Not applicable to all scenarios e.g. mid-treatment

Conclusion

Dental professionals have a responsibility, both as care-providers and moral human beings, to actively tackle racism and discrimination within the dental community. This article has highlighted the ways in which you can elicit positive change, which we hope will be taken on-board by its readers. For those inspired to adopt a more active approach, the workshop detailed in this article may be used as a framework for training within their own dental teams. The power of small changes must not be underestimated. Through shared determination we will move ever-closer to a society free of inequality and discrimination. ◆