No One Size Fits All: A Qualitative Study of Clerkship Medical Students' Perceptions of Ideal Supervisor Responses to Microaggressions

Academic Leadership Academy Summer Program: Clerkship Transition Preparation for Underrepresented in Medicine Medical Students

PROBLEM

Enhancing workforce diversity by increasing the recruitment of students who have been historically excluded/underrepresented in medicine (UIM) is critical to addressing healthcare inequities. However, these efforts are inadequate when undertaken without also supporting students' success. The transition to clerkships is an important and often difficult to navigate inflection point in medical training where attention to the specific needs of UIM students is critical.

INTERVENTION

We describe the design, delivery, and three-year evaluation outcomes of a strengths-based program for UIM second year medical students. The program emphasizes three content areas: clinical presentations/clinical reasoning, community building, and surfacing the hidden curriculum. Students are taught and mentored by faculty, residents, and senior students from UIM backgrounds, creating a supportive space for learning.

CONTEXT

The program is offered to all UIM medical students; the centerpiece of the program is an intensive four-day curriculum just before the start of students' second year. Program evaluation with participant focus groups utilized an anti-deficit approach by looking to students as experts in their own learning. During focus groups mid-way through clerkships, students reflected on the program and identified which elements were most helpful to their clerkship transition as well as areas for programmatic improvement.

IMPACT

Students valued key clinical skills learning prior to clerkships, anticipatory guidance on the professional landscape, solidarity and learning with other UIM students and faculty, and the creation of a community of peers. Students noted increased confidence, self-efficacy and comfort when starting clerkships.

LESSONS LEARNED

There is power in learning in a community connected by shared identities and grounded in the strengths of UIM learners, particularly when discussing aspects of the hidden curriculum in clerkships and sharing specific challenges and strategies for success relevant to UIM learners. We learned that while students found unique benefits to preparing for clerkships in a community of UIM students, near peers, and faculty, future programs could be enhanced by pairing this formal intensive curriculum with more longitudinal opportunities for community building, mentoring, and career guidance.

Characterizing Asian American medical students' experiences with microaggression and the impact on their well-being

PURPOSE

This mixed-methods study quantified and characterized incidents of microaggressions experienced by Asian American medical students. The authors report on their impact and suggest improvements to create a more equitable and supportive learning environment.

METHOD

Quantitative and qualitative data were collected from 305 participants who self-identified as Asian American or Pacific Islander. An online, anonymous survey was sent to US medical students through the Asian Pacific American Medical Student Association (APAMSA). Questions explored incidence, characteristics of, and response to microaggressions. We conducted four focus groups to further characterize students' experiences. Data were organized and coded, and thematic analysis was used to identify core themes.

RESULTS

Racial microaggressions were prevalent among Asian American medical students. Nearly 70% (n = 213) of survey respondents reported experiencing at least one incident during their medical training to date. The most common perpetrators were patients (n = 151, 70.9%) and fellow medical students (n = 126, 59.2%), followed by professors (n = 90, 42.3%). The most prevalent themes included being perceived as a perpetual foreigner, the assumption of timidness, and ascription of the model minority myth. Students rarely reported the incident and usually did not respond immediately due to fear of retaliation, uncertainties about the experience or how to respond appropriately, and perception that they would bear the burden of advocacy alone. Experiences with microaggressions led to feelings of frustration and burnout and had a negative impact on mental health. Recommendations were made to improve the anonymous reporting systems in medical schools, and to increase diversity and inclusion in medical education and leadership.

CONCLUSIONS

Asian American medical students face high exposure to racial microaggressions during their medical education that adversely impact their mental health. Changes are needed in medical training to create a more equitable and inclusive learning environment.

Impact of diversity representation in art on pre-health professions students' sense of belonging: A randomized experimental study

BACKGROUND

For learners underrepresented in medicine (UIM), a heightened sense of belonging may be critical to creating shared awareness of diversity and fostering an inclusive educational environment. Despite ongoing efforts from academic medical institutions to promote and retain diverse individuals, few studies have investigated the foundational role of pre-health professions education in shaping students' sense of belonging, and fewer still have leveraged the potential of arts- and humanities-based approaches in doing so. This study aimed to evaluate the perceived impact of race- and gender-diverse visual representations of health professionals on pre-health students' sense of belonging.

METHODS

Twenty-eight pre-health professions students at one large undergraduate academic institution were randomized to one of two study groups. Each group participated in a visual arts-based workshop to discuss images depicting either gender- and race-diverse or non-diverse health professionals. All participants completed a pre- and post-workshop survey consisting of select items from the Professional Identity Questionnaire (PIQ), as well as an additional open-ended survey after viewing the images from the other study group. Changes in PIQ item scores were analyzed using chi-square statistics, and free-text survey responses underwent thematic analysis.

RESULTS

Although PIQ item score changes were not statistically significant in either group, both showed an overall directional increase that was more pronounced in the study group exposed to diverse images. Qualitative analysis of responses to open-ended survey items were grouped into four overarching themes: "Diversity, equity, and inclusion (DEI) converges with other aspects of intersectional identity," "sense of belonging drives motivation," "perceptions of medicine are shaped early in training," and "cross-group exposure stimulates metacognitive thinking."

CONCLUSION

Integrating arts and humanities programming into pre-health professions education may help cultivate a sense of belonging among UIM students, providing a robust platform for the critical dialogues essential in advancing inclusivity within healthcare settings.

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

Creating an anti-ableist learning environment: Development of a novel disability-related microaggressions session for medical and dental students and mixed methods analysis of impact on learning and empowerment

BACKGROUND

Disability-related microaggressions are unique among microaggressions in the assumptions they reflect and the verbal and non-verbal forms they take. They impact patients and providers alike. Yet, medical and dental students are not routinely educated about disability-related microaggressions. A medical school student-faculty team harnessed Kern's six-step curriculum design process to co-produce a novel 90-min educational intervention centered on recognizing and responding to disability-related microaggressions. The session was piloted in February 2022 as a required element of the school's mandatory professional development training for first-year medical and dental students.

OBJECTIVE

This mixed-methods study examined session impact on student-reported learning pertinent to addressing and mitigating disability-related microaggressions.

METHODS

Voluntary surveys were distributed to all first-year students to capture pre-/post-session self-assessment of knowledge, skills, and comfort, as well as post-session reflection on lessons learned. Quantitative data was analyzed using summary statistics, unpaired t-tests, and Mann Whitney U tests; qualitative data was analyzed using a hybrid inductive-deductive approach.

RESULTS

Survey response rate was 61 % (100/164) pre-session and 25 % (41/164) post-session. Post-session, there was significantly increased student agreement with statements addressing microaggressions knowledge, comfort teaching others, and strategies to support disability-sensitive workplaces. Post-session narrative reflections revealed learning within five themes: nature of microaggressions, identifying microaggressions, preventing microaggressions, responding to microaggressions, and medical student empowerment. Ninety-three percent of post-session respondents (38/41) agreed the session empowered them to actively contribute to anti-ableist learning environments.

CONCLUSIONS

The pilot educational intervention provides a promising strategy to foster anti-ableism and advocacy among first-year medical/dental students. While limited by low response rate, small sample size, participant self-selection for survey participation, and unlinked individual pre- and post-session responses, mixed methods analysis suggests the session had a positive impact on student action-oriented knowledge and empowerment.

Diversity, equity, and inclusion (DEI) in medical education: DEI at the bedside

BACKGROUND

The ability to recognize and address bias is an important communication skill not typically addressed during training. We describe the design of an educational curriculum that aims to identify and change behavior related to diversity, equity, and inclusion (DEI). "DEI at the Bedside" uses the existing infrastructure of bedside teaching and provides a tool to normalize DEI discussions and develop skills to address bias during a neurology inpatient rotation.

METHODS

As part of traditional clinical rounds, team members on an inpatient service shared experiences with DEI topics, including bias. The team developed potential responses should they encounter a similar situation in the future. We report the results of our needs assessment and curriculum development to evaluate the feasibility of incorporating a DEI educational curriculum in the neurology inpatient setting.

RESULTS

Forty-two DEI experiences were recorded. Medical students were the most frequent discussants (44%). Direction of bias occurred between healthcare team members (33%), against patients (31%), and patients against healthcare team members (28%). Experiences ranged from microaggressions to explicit comments of racism, sexism, and homophobia.

CONCLUSIONS

Based on needs assessment data, we developed a DEI educational curriculum for the inpatient neurology setting aimed to improve knowledge and skills related to DEI topics as well as to normalize conversation of DEI in the clinical setting. Additional study will demonstrate whether this initiative translates into measurable and sustained improvement in knowledge of how bias and disparity show up in the clinical setting and behavioral intent to discuss and address them.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students

INTRODUCTION

Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment.

METHODS

This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations.

RESULTS

Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment.

DISCUSSION

Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Exploring the impact of microaggressions on the genetic counseling student-supervisor relationship: A qualitative study

Genetic counseling students with minoritized identities have reported experiencing microaggressions throughout graduate training, including from fieldwork supervisors. However, the impacts of these fieldwork experiences have not been thoroughly investigated. As supervision is known to be integral to genetic counseling students' skill development and success, the purpose of this qualitative study was to explore the impact of microaggressions on student training, with a specific focus on the supervisory working alliance. To achieve this goal, we conducted 11 interviews with recent genetic counseling graduates (2019-2021) who reported experiencing at least one microaggression from a fieldwork supervisor during graduate school training. Purposive sampling was used to prioritize interviewees who identified as underrepresented in the field due to race, ethnicity, gender identity, sexual orientation, and/or disability status. All interviewees were initially recruited as part of a larger mixed-methods study investigating the frequency and types of microaggressions genetic counseling students experience from fieldwork supervisors. Interview questions explored the time period before a microaggression event, during the event, and after. Qualitative thematic analysis resulted in four themes, three of which are presented in this paper: (1) Impact of microaggressions, (2) Barriers to reporting microaggressions, and (3) Experience reporting microaggressions. Microaggressions from supervisors were shown to impair the psychological well-being of participants and hinder learning opportunities. These experiences led participants to question their choice of profession and avoid time in clinic, ultimately constraining the development of strong supervisory working alliances. Some participants did not report microaggressions due to fear of negative repercussions, and those who did described defensive responses which harmed students' relationships with program leadership. This study reveals opportunities for supervisors to improve student training conditions by centering students' feelings and experiences, increasing open and honest communication, and extending psychosocial tools to supervision. Additionally, graduate programs are encouraged to establish structured reporting protocols for students and evaluate current shortcomings in equity and inclusion initiatives.

It is Challenging to Shift the Norm: Exploring how to Anticipate and Address Microaggressions in Clinical Learning Environments

Purpose

Increased attention to improving a culture of belonging in clinical learning environments has led to various approaches to addressing microaggressions. However, most approaches in the literature focus on responding or reacting to microaggressions with insufficient attention to building trust before microaggressions might occur. Research on microaggressions in clinical learning environments suggests anticipatory or pre-emptive conversations about microaggressions may foster greater trust. In this study, the authors explored how diverse participants perceived the experience of anticipatory conversations about potential microaggressions. Overall, the authors sought to gain a deeper understanding of how pre-emptive and anticipatory conversations may influence an organization's approach to addressing microaggressions in clinical learning environments.

Methods

The authors utilized constructivist grounded theory methodology and conducted individual qualitative interviews with 21 participants in an academic department within a larger health sciences center in the United States.

Results

Findings suggest that anticipatory conversations about microaggressions were challenging due to existing norms in dynamic clinical learning and working environments. Participants shared that the idea of anticipating microaggressions elicited dissonance. Conversations about microaggressions could potentially be facilitated through leaders who role model vulnerability, organizational supports, and an individualized approach for each team member and their role within a complex hierarchical organization.

Discussion

Anticipating and addressing microaggressions in clinical learning environments holds tremendous potential, however, any conversations about personal identity remain challenging in medical and healthcare environments. This study suggests that any attempts to address microaggressions requires attention to cultural norms within healthcare environments and the ways that hierarchical organizations can constrain individual agency.

"As a psychiatry resident I am invited to explore my identity. But when I accept that invitation, I still encounter a wall." A qualitative study on inclusion experienced by psychiatry residents with a migration background, sexual minority identity and/or working-class background

Diversity in terms of class, sexual identity and migration background among medical students in high income countries has increased greatly in recent decades. Some research into the experiences of these new groups of doctors has been performed. However, no previous research into the experiences of psychiatry residents specifically, is known. This qualitative study investigates how psychiatry residents, from these minoritized groups, experience their training regarding inclusion. Inclusion is defined as the degree to which one's needs for connection and for being valued in one's uniqueness, is satisfied. In-depth interviews with 16 psychiatry residents were conducted. These interviews were transcribed and coded using MaxQDA software. Initial themes that were constructed, were explored further in subsequent interviews and linked to literature. Finally, the developed themes were ordered in a model conceptualizing inclusion. Participants reported high belongingness within psychiatry training. Their experienced value in uniqueness, however, was generally quite low. Participants reported to experience little interest in and sensitivity for their perspectives and lived experiences from their co-workers. When faced with stigmatization and discrimination, participants reported lack of support from their colleagues. Assimilation was found to be the most frequently used coping strategy in dealing with diversity. Participants seemed to conform to the 'neutral' norm and experienced barriers in expressing themselves. Through this mechanism of assimilation, the added value that participants might bring with their unique knowledge and lived experiences was not used, both in patient care and in creating an inclusive climate within the organization. Moreover, assimilation is associated with psychological strain.

From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students

PURPOSE

Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners.

METHOD

This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes.

RESULTS

Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development.

CONCLUSIONS

Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Evolution of the Oncologist Clinician Educator

Today’s oncologist clinician educator must promote DEI, well-being, and educational scholarship.

Discrimination 911: A Novel Response Framework to Teach Bystanders to Become Upstanders When Facing Microaggressions

PROBLEM

Microaggressions are pervasive in daily life, including in undergraduate and graduate medical education and across health care settings. The authors created a response framework (i.e., a series of algorithms) to help bystanders (i.e., health care team members) become upstanders when witnessing discrimination by the patient or patient's family toward colleagues at the bedside during patient care, Texas Children's Hospital, August 2020 to December 2021.

APPROACH

Similar to a medical "code blue," microaggressions in the context of patient care are foreseeable yet unpredictable, emotionally jarring, and often high-stakes. Modeled after algorithms for medical resuscitations, the authors used existing literature to create a series of algorithms, called Discrimination 911, to teach individuals how to intervene as an upstander when witnessing instances of discrimination. The algorithms "diagnose" the discriminatory act, provide a process to respond with scripted language, and subsequently support a colleague who was targeted. The algorithms are accompanied by training on communication skills and diversity, equity, and inclusion principles via a 3-hour workshop that includes didactics and iterative role play. The algorithms were designed in the summer of 2020 and refined through pilot workshops throughout 2021.

OUTCOMES

As of August 2022, 5 workshops have been conducted with 91 participants who also completed the post-workshop survey. Eighty (88%) participants reported witnessing discrimination from a patient or patient's family toward a health care professional, and 89 (98%) participants stated that they would use this training to make changes in their practice.

NEXT STEPS

The next phase of the project will involve continued dissemination of the workshop and algorithms as well as developing a plan to obtain follow-up data in an incremental fashion to assess for behavior change. To reach this goal, the authors have considered changing the format of the training and are planning to train additional facilitators.

'Where are you really from?': a qualitative study of racial microaggressions and the impact on medical students in the UK

OBJECTIVE

To explore graduate-entry medical students' experiences of racial microaggressions, the impact of these on learning, performance and attainment, and their views on how these can be reduced.

DESIGN

Qualitative study using semistructured focus groups and group interviews.

SETTING

UK.

PARTICIPANTS

20 graduate-entry medical students were recruited using volunteer and snowball sampling; all students self-identified as being from racially minoritised (RM) backgrounds.

RESULTS

Participants reported experiencing numerous types of racial microaggressions during their time at medical school. Students' accounts highlighted how these impacted directly and indirectly on their learning, performance and well-being. Students frequently reported feeling uncomfortable and out of place in teaching sessions and clinical placements. Students also reported feeling invisible and ignored in placements and not being offered the same learning opportunities as their white counterparts. This led to lack of access to learning experiences or disengagement from learning. Many participants described how being from an RM background was associated with feelings of apprehension and having their 'guards up', particularly at the start of new clinical placements. This was perceived to be an additional burden that was not experienced by their white counterparts. Students suggested that future interventions should focus on institutional changes to diversify student and staff populations; shifting the culture to build and maintain inclusive environments; encouraging open, transparent conversations around racism and promptly managing any student-reported racial experiences.

CONCLUSION

RM students in this study reported that their medical school experiences were regularly affected by racial microaggressions. Students believed these microaggressions impeded their learning, performance and well-being. It is imperative that institutions increase their awareness of the difficulties faced by RM students and provide appropriate support in challenging times. Fostering inclusion as well as embedding antiracist pedagogy into medical curricula is likely to be beneficial.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

Opportunities and challenges in discussing racism during primary care visits

OBJECTIVE

To understand how patients and primary care practitioners (PCPs) discuss racism and their perspectives on having these conversations during primary care visits.

DATA SOURCES/STUDY SETTING

We conducted semi-structured interviews from September 2020-March 2021 at a Federally Qualified Health Center in the San Francisco Bay Area.

STUDY DESIGN

We conducted an inductive qualitative descriptive pilot study using one-on-one, semi-structured interviews with 5 members of a Patient Advisory Council and 10 internal medicine PCPs.

DATA COLLECTION/EXTRACTION METHODS

Interviews were conducted via video conferencing, recorded, and transcribed. An iterative analytic process was used to thematically assess participants' experiences and perspectives and identify key themes.

PRINCIPAL FINDINGS

Patients and PCPs identified benefits from engaging in conversations about racism during primary care visits and noted challenges and concerns. Patients and PCPs highlighted strategies to advance communication about racism in primary care.

CONCLUSIONS

Initiating conversations about racism with patients in primary care can be meaningful, but also has risks. More research is needed for deeper exploration of patients' perspectives and development of trainings. Improving how PCPs communicate with patients about racism represents an opportunity to advance antiracism in medicine and improve health outcomes for individuals who have historically been poorly served by our health care system.

Factors influencing LGBTQ+ disclosure decision-making by Canadian health professionals: A qualitative study

Disclosure of LGBTQ+ identities at work may reap benefits, but may also exacerbate harms. Faced with ambiguous outcomes, people engage in complex concealment/disclosure decision-making. For health professionals, in contexts of pervasive heteronormativity where disclosure to patients/clients is deemed to violate professional boundaries, stakes are high. This qualitative study with 13 LGBTQ+ health professionals across Canada used semi-structured interviews to explore factors affecting disclosure decision-making, particularly attending to power structures at multiple levels. Most participants engaged in constant risk-benefit assessment, disclosing strategically to colleagues, rarely to clients/patients. At the individual level they were affected by degree of LGBTQ+ visibility. At the institutional level they were affected by the culture of particular professional fields and practice settings, including type of care and type of patients/clients, as well as colleague interactions. Professional power-held by them, and held by others over them-directly affected disclosures. Finally, intersections of queer identities with other privileged or marginalized identities complicated disclosures. Power relations in the health professions shape LGBTQ+ identity disclosures in complex ways, with unpredictable outcomes. Concepts of professionalism are infused with heteronormativity, serving to regulate the gender and sexual identity expression of queer professionals. Disrupting heteronormativity is essential to forge more open professional cultures.

Positive yet problematic: Lived experiences of racial and ethnic minority medical students during rural and urban underserved clinical rotations

PURPOSE OF STUDY

Medical students who identify as Black, Indigenous, and People of Color (BIPOC) regularly experience mistreatment and discrimination. This study sought to understand these student experiences during rotations in rural and urban underserved community teaching sites.

METHODS

Self-identified BIPOC medical students who completed the University of Washington School of Medicine's Rural Underserved Opportunities Program from 2019 through 2021 were invited to participate in a 60- to 90-minute focus group discussion via Zoom. From August to September 2021, 4 focus groups and 1 individual interview were conducted with a total of 12 participants. A current BIPOC medical student facilitated the sessions utilizing questions developed by the research team. Four study team members coded transcripts for key themes related to experiences of microaggressions.

FINDINGS

All participants reported having an overall positive experience, but everyone also witnessed and/or experienced at least 1 microaggression. Unlike those in urban placements, participants placed in rural sites expressed anxiety about being in predominantly White communities and experienced feelings of racial and/or ethnic isolation during the rotation. Participants recommended that rural preceptors identify themselves as trusted advocates and the program should prioritize placing BIPOC students at diverse clinical sites.

CONCLUSIONS

Medical schools must take action to address the mistreatment of BIPOC medical students in the clinical environment. Schools and rural training sites need to consider how to best support students to create an equitable learning environment and recruit more BIPOC physicians to rural practice.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors’ actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a prospective study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors’ behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner’s autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

"Ah, it's best not to mention that here:" Experiences of LGBTQ+ health professionals in (heteronormative) workplaces in Canada

Introduction

Despite human rights protections for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people, LGBTQ+ professionals may continue to experience discrimination working in heteronormative systems and spaces.

Methods

In this qualitative study 13 health professionals (nurses, occupational therapists, and physicians) from across Canada participated in in-depth qualitative interviews to explore their experiences with work-related microaggressions and heteronormativity.

Results

Heterosexist microaggressions from both patients/clients and colleagues were the norm, perpetuating and bolstered by heteronormative workplace and professional cultures. In turn, LGBTQ+ professionals navigated disclosure-decision-making, in power-laden contexts where all options carried potential negative consequences.

Discussion

Drawing on the notion of "heteroprofessionalism," we argue that the concept of professional carries encoded within it demands that the occupant of that category be-or present as-heterosexual, an unmarked status that can be readily desexualized. Acknowledging sex and sexuality disrupts "professionalism." We argue that such disruption, indeed dissention, is necessary to open (hetero)professional spaces to LGBTQ+ workers.

A Narrative Review of Key Studies in Medical Education in 2021: Applying Current Literature to Educational Practice and Scholarship

To remain at the forefront of clinical practice and pedagogy, pediatric medical educators must stay informed of the latest research. Yet familiarization with the growing body of literature in both pediatrics and medical education is a near-impossible task for the busy medical educator. The purpose of this annotated bibliography is to summarize key manuscripts in medical education published in 2021 that have the potential to significantly influence a pediatric medical educator's practice. Using a 2-staged iterative process, discrete author pairs reviewed 1599 abstracts from 16 medical education and specialty journals. In summary, 16 manuscripts were selected and grouped into the following 6 domains: assessment and feedback, USMLE Step 1 changes, communication, wellness, diversity and inclusion, and professional development. The authors provide abridged summaries and high-yield take-aways from these manuscripts that may impact educational practices in pediatrics. This year, we also provide a 6-year retrospective review of the journals that have had selected articles for this annotated bibliography since inception.

What Happened and Why: Responding to Racism, Discrimination, and Microaggressions in the Clinical Learning Environment

INTRODUCTION

Within clinical learning environments, medical students are uniquely faced with power differentials that make acts of racism, discrimination, and microaggressions (RDM) challenging to address. Experiences of microaggressions and mistreatment are correlated with higher rates of positive depression screening and lower satisfaction with medical training. We developed a curriculum for medical students beginning clerkship rotations to promote the recognition of and response to RDM.

METHODS

Guided by generalized and targeted needs assessments, we created a case-based curriculum to practice communication responses to address RDM. The communication framework, a 6Ds approach, was developed through adaptation and expansion of established and previously learned communication upstander frameworks. Cases were collected through volunteer submission and revised to maintain anonymity. Faculty and senior medical students cofacilitated the small-group sessions. During the sessions, students reviewed the communication framework, explored their natural response strategies, and practiced all response strategies.

RESULTS

Of 196 workshop participants, 152 (78%) completed the evaluation surveys. Pre- and postsession survey cohort comparison demonstrated a significant increase in students' awareness of instances of RDM (from 34% to 46%), knowledge of communication strategies to mitigate RDM (presession M = 3.4, postsession M = 4.6, p < .01), and confidence to address RDM (presession M = 3.0, postsession M = 4.4, p < .01).

DISCUSSION

Students gained valuable communication skills from interactive sessions addressing RDM using empathy, reflection, and relatability. The workshop empowered students to feel prepared to enter professional teams and effectively mitigate harmful discourse.

Moving From Theory to Practice in Oncology Education When Virtual Is Your Reality

Evidence-based education is crucial for meeting the evolving needs of learners in the oncology workforce, given the growing demand for well-trained providers and the rapidly changing complexities of cancer care. With the onset of the severe acute respiratory syndrome coronavirus 2 pandemic, innovative means of delivering educational content in a virtual setting have become a necessary reality. Knowledge of learning science can be translated into concrete, pragmatic methods for using evidence-based education in a virtual world and affords important opportunities for innovation and inclusion across a broad network of educators and learners. We offer key insights and tools to promote attention to and agility with teaching in virtual settings to meet the needs of contemporary educators and learners.

Disruption and Dissonance: Exploring Constructive Tensions Within Research in Medical Education

The academic medicine community has experienced an unprecedented level of disruption in recent years. In this context, the authors consider how the disruptions have impacted the state of research in medical education (RIME). The articles in this year's RIME supplement reflect several constructive tensions that provide insight on future for the field. In this commentary, the authors discuss themes and propose a framework for the future. Recommendations include: normalizing help seeking during times of disruption and uncertainty, contextualizing the application of complex approaches to assessment, advancing and problematizing innovation, and recognizing the deeply embedded and systemic nature of inequities.