On this episode of the Academic Medicine Podcast, Meghan O’Brien, MD, MBE, and Research in Medical Education (RIME) Committee members Tasha Wyatt, PhD, and Javeed Sukhera, MD, PhD, join host Toni Gallo to discuss new research into faculty perspectives on responding to microaggressions targeting medical students in the clinical learning environment. They explore several tensions that affected how faculty responded to the microaggressions in the study scenarios as well as strategies the faculty used to respond effectively.
This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.
This is the final episode in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field.
A transcript is below.
Read the RIME article discussed in this episode:
- O’Brien MT, Bullock JL, Minhas PK, et al. From eggshells to action: A qualitative study of faculty experience responding to microaggressions targeting medical students. Acad Med. 2023;98:S79-S89.
Read the authors’ other article mentioned in this episode:
- Bullock JL, O’Brien MT, Minhas PK, Fernandez A, Lupton KL, Hauer KE. No one size fits all: A qualitative study of clerkship medical students’ perceptions of ideal supervisor responses to microaggressions. Acad Med. 2021;96:S71–S80.
Transcript
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Toni Gallo
Before we get into today’s episode, I’m really excited to announce that you can now claim CME credit for listening to this podcast. Academic Medicine is offering this service free of charge. There’s no cost to you. All you have to do is visit academicmedicineblog.org/cme, listen to the eight episodes listed, then follow the instructions to claim your credit. This is an annual activity, so you can claim these credits once between now and next July. Every year, we’ll be updating the list of included episodes and additional credits will be available. You can find more information at academicmedicineblog.org/cme, or you can email academicmedicine@aamc.org with questions. As always, thanks for listening, and here’s today’s episode.
Welcome to the Academic Medicine Podcast. I’m Toni Gallo. Every year, Academic Medicine publishes the proceedings of the annual Research in Medical Education, or RIME, sessions that take place at the AAMC’s Learn Serve Lead meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the Learn Serve Lead Meeting, which is taking place in Seattle, Washington, later this week. The RIME papers are available now to read for free on academicmedicine.org.
As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research and its implications for the field. On last week’s episode, I spoke to Dr. Carrie Chen and Dr. Terry Kind about their study exploring unauthorized collaborations among medical students. Today, for the third and final of this year’s RIME conversations, I’m joined by Dr. Meghan O’Brien, author of the paper “From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students.” Also joining us today are RIME committee members, Dr. Tasha Wyatt and Dr. Javeed Sukhera.
So welcome, everyone, to the podcast today. Let’s start with some introductions. Meghan, you want to go first?
Meghan O’Brien
Yes. Thanks so much for having me. It’s a wonderful opportunity to be able to share our work. I’m Meghan O’Brien. I’m an assistant professor of internal medicine at UCSF and a general internist practicing hospital medicine at our county hospital, San Francisco General Hospital. I have an additional board certification in addiction medicine through the practice pathway, and I’m also a medical educator, so I serve as a bridges coach for medical students in the San Joaquin Valley PRIME Program, which is a program that seeks to address a physician shortage in California’s Central Valley. I also support faculty development doing some workshops supporting the Academy of Medical Educators Teaching Observation Program, upper division, and then serving as interim faculty development director for our Division of Hospital Medicine. Thanks so much for the invitation to be here.
Toni Gallo
Wonderful. Javeed?
Javeed Sukhera
Hi, my name is Javeed Sukhera. I’m the chair and chief of psychiatry at Hartford Hospital and the Institute of Living in Hartford, Connecticut, where I’m also an associate clinical professor in the Department of Psychiatry at the Yale School of Medicine and associate professor at the University of Connecticut. I’m an MD-PhD, so I continue to do research in medical education, continue to practice as a child and adolescent psychiatrist. I’m also the incoming co-chair of the RIME Committee.
Toni Gallo
Welcome, and Tasha.
Tasha Wyatt
I am Tasha Wyatt, and I’m an associate professor at the Center for Health Professions Education at Uniformed Services University. Thank you for having us all here today.
Toni Gallo
Thanks for joining our conversation. So Meghan and her coauthors conducted focus groups, and they asked clinical supervisors how they’d respond to scenarios featuring microaggressions targeting medical students in the clinical environment. They analyzed the responses to those scenarios, and they identified some themes. Today we’re going to talk about those themes. We’ll also talk about some of the strategies that the supervisors described to more effectively respond as bystanders to microaggressions, and then we’ll get into some implications for faculty development.
So Meghan, I’m hoping you can start us off with just a little bit more information about what microaggressions are. Maybe you can give us some examples even from the scenarios that were part of your study.
Meghan O’Brien
Microaggressions is a term first coined by the psychiatrist Dr. Chester Pierce back in the ’70s. It’s a term that describes commonplace verbal, behavioral, or environmental indignities that communicate hostility or negative attitudes towards another’s identity. Importantly, they can be intentional or unintentional. I think it’s also important to note that the micro in microaggressions refers to the interpersonal nature of the interaction rather than the size of the impact, which can be quite significant.
There are a few different types of microaggressions as characterized by Sue and colleagues: microassaults, microinsults, and microinvalidations as well as environmental microaggressions. Microassaults are the more egregious overt behavioral attacks, for example, name-calling or refusing care from a provider who is wearing a hijab, for example. Microinsults offend or demean the target often unwittingly. So for example, assuming a physician is either a nurse or from transport, depending on the identities they hold that might seem to another to be more consistent with those roles.
Then microinvalidations minimize or dismiss the target’s experience. So for example, calling students who have been historically excluded from medicine too sensitive or espousing ideas of colorblindness, which ignores or negates people’s lived realities that they have based on how others respond to their racial identity. Then environmental microaggressions are more structural. So for example, walking down a hall in a medical school and seeing portraits of only White men depicted.
When we think about a microaggression, we can think of in terms of the source of the microaggression, the target, and then the bystander. Our study explored faculty bystanders’ experience responding when patients are the source and they’re targeting medical students. We’re interested in this because of the impact that microaggressions have on the learning environment and the compounding harm that happens when faculty supervisors fail to act in response.
Toni Gallo
I want to get into … you just described that the source of the microaggressions in the scenarios in your study were patients, which is, I think, an interesting component of your study. The participants described this kind of tension or having to balance both maintaining their relationship with that patient and also protecting their students, their role as educators. Maybe you can tell us a little bit about how that balance or tension came up in your study, some of the ways that the faculty participants talked about that, and then maybe what that could tell us about responding to microaggressions.
Meghan O’Brien
We chose to focus on this particular orientation of faculty bystander response to patient sources who target learners in our research just to keep our focus narrow, but also because it captures an interesting intersection of hierarchies in which the attending is conferred power, both in the medical educational hierarchy because their position is at the top and then also within the doctor-patient relationship. As you captured, there are responsibilities that come with both these roles, the responsibility to the learner to safeguard the learning environment and make sure that they’re learning and then the responsibility to the patient to do no harm and preserve the therapeutic alliance. This was a difficult balance to navigate, and our faculty participants described a few things as factoring into the calculus of how they responded to microaggressions when navigating this balance.
One thing that came up was their perception of microaggression harm and how they interpreted harm. So microassaults, the more flagrant egregious microaggressions, were universally regarded as harmful and warranting response. But for microinsults, participants diverged on how they perceived harm and often with regards to how they used intent. So some participants interpreted the patient intent behind the microaggression and used that to decide whether it was harmful and thus warranting a response. Whereas others used intent to calibrate response because they regarded all microaggressions as harmful.
In our study, we recruited two groups of faculty: faculty that students had nominated as particularly skilled responders, and these were students in a prior study we did looking at student focus groups. Then we recruited general faculty from the departments of medicine and surgery. We saw that the student-nominated skilled responders and some of our general faculty used intent to calibrate response rather than to decide whether to respond. That is to say they just understood that microaggressions caused harm regardless of intent.
The other thing that factored into the calculus of whether or not to respond was participants’ competence in their ability to respond without making things worse for either the learner or the patient or harming the therapeutic alliance, so again, balancing this dual responsibility. And then a few things went into this understanding of confidence or the perception of their confidence. So, familiarity with responding to microaggressions, whether that’s having responded in the past and understood how skillful they could be with responding, whether that’s as a bystander or responding to microaggressions targeting them. So, identity plays into this a bit. Whether they are emotionally triggered by a microaggression. So even if it’s directed towards students, there can be an emotional response and impact in the bystander that erodes emotional bandwidth and reserve to be able to respond, and then understanding of learner preferences. So some faculty interpreted or intuited learner preferences by body language and other signals, whereas other faculty actually preemptively asked. For the faculty who preemptively asked learner preferences for their action in the event of a microaggression targeting students, there was more confidence that they could act in alignment with student preferences and get it right. That seemed to facilitate response.
So I think this matters because it opens up specific inroads that can support action. If we can develop a shared mental model of microaggressions as being harmful regardless of intent or develop skills to elicit learner preferences or practicing calibration and language based on learner intent so that we can preserve relationship with the patients, I think these things can empower action and be concrete skills that we can focus on.
Toni Gallo
You have set up the rest of our conversation so well, but I want to turn it over to Javeed and Tasha now, if there’s anything from your own research or experience with faculty development and patient care that you want to jump in with regarding Meghan’s study.
Javeed Sukhera
So maybe I can start. There’s so many things that are amazing about this work, and I’m not even sure where to begin. But what I want to highlight is that … why this work is important is because there isn’t a lot of research in health professions education that provides the kinds of insights and implications that this work does. We often research things in a theoretical way without thinking about implications that can help guide us about what to do in which context. In a sea of research on things like bystander training that only get to the surface, I think taking this deeper dive into how faculty grapple with these tensions is exactly where we need to go. So kudos to you and the author team.
Again, there’s so many different ways I want to understand your results, but one of the things I think that’s really fascinating is that the identity of the faculty really influenced how they responded. In some of our own work, we found that we have a tendency to armor up in health professions, that we compartmentalize our identities, and that it’s often hard to acknowledge that, and that that can sometimes be a barrier to both noticing when a microaggression is taking place or a barrier to the safety or risk that a faculty perceives when they’re deciding whether or not they should respond.
So I’m curious about what you found and what you would suggest might be the implications around how there is that no one-size-fits all and the different personal or social identities of faculty might actually be influencing their interpretations, their inferences, and what they’re attributing as potential microaggressions.
Meghan O’Brien
Yeah, it’s a great question, and I think noticing was certainly a theme that came up in our work, and noticing was identified as a prerequisite to being able to respond. As you described, the experiences we’ve had in our life which are shaped by the identities we hold influence our ability to notice and also the capacity to respond. So if we’ve had prior experiences that are traumatic in some regard, that may limit our ability to respond even if we notice because we just don’t have the emotional bandwidth.
One of the things that was really interesting is the way that past negative experiences with microaggressions, maybe it caused a numbness to noticing them when they occurred in the learning space now. So this came up among women participants. One, for example, described her skin of perpetual thickness, where she recounted a story where learners on the team or residents identified a patient microaggression targeting the faculty member. She was taken aback and said, “I didn’t even notice it because I’ve been so indoctrinated or trained to ignore it because it happens so commonly.” I think this speaks to the parts of ourselves that we tune out to endure, at times, toxic professional environments and the way that the impact of those toxicities can reverberate through us.
I think it can also be a point of empathy. So as students and learners are demanding faculty respond to these indignities, it might be a point of empathy that we can understand at least a small part of faculty in action may be attributed to having endured negative experiences themselves and having developed this coping mechanism.
Then I also think it speaks to the power of the directional flow of education and knowledge. So faculty described learning from more junior trainees and students about how they deserve to be treated in clinical spaces. So there’s definitely a lot of gratitude and almost like a touch of grief that it’s taking the awareness that they’re getting from students to realize that they don’t actually have to endure and tolerate bad behavior from patients.
So I think this bidirectional culture change, whether it’s as we do education of faculty and it’s top down, I think a lot of it is very powerfully driven by students and learners from the bottom up. To acknowledge that and flatten the hierarchies to facilitate this mutual skill building, I think is a really important idea and important powerful thing that we can harness.
Tasha Wyatt
Meghan, you actually ended up on my favorite topic, which is the resistance among medical trainees for changing the culture of medical education. I noted that in your paper, and I found that incredibly interesting. I will say I do not see this at every institution. I think the institution in which your study sat is special in some ways. I’m wondering what clues you’ve been given to suggest where this shift is originating. So why is it that attendings will now look to learners as sources of legitimate knowledge and listen to them to be able to rethink their actions in a clinical environment? If you have any clues around that, I would really appreciate hearing it.
Meghan O’Brien
UCSF where I train and practice has a long legacy of student activism. So beginning with the White Coats for Black Lives student die-in many years ago, it really called for and demanded a culture change in the clinical medical education space. So UCSF, to its credit, responded by funding a, I think it was a five-year initiative of Differences Matter where it sought to increase the diversity of the faculty, increase training, increase recruitment/retention and drive culture change. We still have a lot of work to do, and it’s constantly driven by students. We are responding to the things that, in many ways, that they’re coming in with fresh eyes and they expect better in part because we told them that we are better. So when they arrive at UCSF and they say, “Okay, well this is a little different than we bargained for, than that was held out to us. We want you to make good on your promise.” UCSF is filled with educators who are very committed to doing this, but institutional change is slow, and it’s messy, and it’s hard. So I really think a lot of credit goes to the students.
I think particularly around issues of identity and racism, the people who are in medicine realize that the medical health care system and medical education, these systems have historically been dominated by White men and that we are living in those legacies and that we’ve been acculturated into them through our own training that we have a lot of unlearning to do. So I think students are really a generative force to calling for that unlearning. I think we have to take responsibility for our own education as well and not burden the students with the responsibility of teaching us, but certainly we have the responsibility to respond to their call for action. It is a pretty unique environment, but we still have … a lot of good progress and a lot of work to do still.
Javeed Sukhera
That issue, though, of the upending of power structures I think is really fascinating. In the study, you showed that the faculty had to navigate this tension between being credible and leveraging their power in a way, but also embracing their vulnerability, which I think is very fascinating. It speaks also to similar tensions I’ve explored in my work. There was actually a quote that said, “We’re seen as the most knowledgeable people in the room, and so we have to be able to talk authoritatively on it. Yet, I’m not the authority. I have to bring some humility to this and let people teach each other.”
I think this is really fascinating, and I think we should all be leaning a bit into how faculty or folks navigate this tension, but I also noticed that you used a pre-brief, which I’m a huge fan of. A pre-brief, as I understand, it is an anticipatory conversation that helps neutralize power differential by inviting both teacher and faculty to talk about their preferences should they encounter a microaggression. But at the same time, there is a greater onus on faculty to role model this while they might be dealing with their own fears and tensions about bringing some of this into the room. So how do you think this tension between vulnerability and credibility should play out?
Meghan O’Brien
It’s interesting, and I think this goes back to the experience of hierarchies where faculty are positioned as an expert or leader but then associated pressure to “get it right.” That pressure could be paralyzing for some of our participants, as they described. As educators in positions, we have to maintain credibility in order to do our jobs. In thinking about our results and our analysis, it took a little bit of a deeper dive into credibility. I like the descriptions of it as being a reminder that it’s socially constructed and it’s contextual, meaning what marks us as credible in the eyes of our students and our patients is influenced by social and professional expectations of us as physicians and educators and also intersects with our identities, right? Certain identities are conferred a greater sense of credibility, and others are interpreted as being less credible. So they have to overcome identity perceptions in order to maintain credibility.
But because faculty supervisors are considered the most knowledgeable in the room and they experience this pressure to get it right, when they confront a microaggression, there’s this automatic injection of vulnerability into the professional space. That can be because microaggressions are jarring. Whether you’re a witness to it or you’re targeted by a microaggression, there’s a vulnerability of not knowing if you should respond or if a response is desired, and if you want to respond how to respond, there’s this fear of responding unskillfully in a way that will erode this credibility. So in order to act, we have to figure out how to navigate vulnerability while having a sense that we can maintain credibility, as you were saying, while doing our job.
So as you mentioned, pre-briefing is one of the things that surfaced and one of the themes that surfaced in our work that we think can help maintain credibility. The way I think this is working is because if we’re preemptively establishing learner preferences for our action in the occurrence of a microaggression, a vulnerable moment, then we are preemptively establishing what a credible response is if we are able to act in alignment with learner preferences. That’s in the context of that particular learner. So it takes the guesswork out of saying, “How can I as an educator have an appropriate response in a moment that maintains my credibility?” So I think that’s the function of the pre-brief there.
The other thing I think was happening is this concept of intellectual candor, which is described by educational researchers, Molloy and Beerman, as this improvisational expression of doubts, thought processes, dilemmas, and failures to share and promote collective learning. It invites this reciprocal vulnerability and models of balance of credibility and vulnerability inherent in learning any new skill. So responding to microaggressions is challenging. There’s a vulnerability to it. We often weren’t taught how to do it, and so when we model the vulnerability of trying to figure it out, like if it doesn’t go well, if we maybe made a misstep, what we saw is that our student-nominated faculty in particular would be able to harness the occurrence of a microaggression as a time for reflection, as a time to model this balance between vulnerability and credibility for the purposes of improving their own response and also the response of their learners.
So I think using intellectual candor, which none of our participants used that term, but I think in hindsight that’s what they were describing, modeling this tension, this grappling can really use the unfortunate occurrence of microaggressions as a transformative moment for learning. I think that can preserve some of the credibility. It requires trust and it invites trust, and it requires a bit of this vulnerability-credibility balance.
Toni Gallo
Building on the idea of a pre-brief, maybe you can tell us a little bit more about what that actually looks like and if there were other strategies that the participants in your study talked about using. We’ve just heard this is not a skill that is necessarily taught, and so I think having tools or set structures that people can follow when they have to respond or want to have that initial conversation before a microaggression occurs can be helpful so faculty aren’t out on their own trying to learn how to do this. So anything else that came out of your study in this area?
Meghan O’Brien
I’ll talk a bit about pre-briefs, and then I can talk about some response strategies. Pre-briefs was a term that we coined in our prior paper with students that was led by Dr. Justin Bullock to describe these anticipatory preference-taking conversations. The participants in our study described doing them in different ways that adapted to their own style and preference and context. Most encompass some acknowledgement that microaggressions happen, that it’s an unfortunate occurrence, and we wish they didn’t. There was an expression of a desire for folks to feel respected so they can focus on learning and some inquiry about the preferences should a microaggression occur, and that is specifically preferences for faculty action. They often included an invitation for feedback if their response missed the mark, so signaling a growth mindset among faculty. They may also acknowledge hierarchies that make responding hard, specifically name responding as a professional skill, which opens up space for students to begin to practice that professional skill.
A few participants made explicit that there won’t be a penalty for student responding if they want to take the lead on responding. The hierarchies complicate student response because of there’s a fear that they may be evaluated negatively or be seen as unprofessional, that can be challenging. So just making explicit that there’s not a penalty if they decide to respond or even not to respond, that’s okay too. I think the main goal of the pre-brief is really just to align with the learner, clarify their preferences, and break down some of the hierarchies and model humility, which can build trust.
Then in terms of response strategies, I think you can check out our paper. There’s a lot of different language that our participants used for different scenarios, and I think that varied, whether it was microassaults, which often required brief non-stigmatizing interventions to interrupt the interaction, but those are for the most egregious microaggressions. Then for microinsults and microinvalidations, there was a whole spectrum of how you could respond. I think the main takeaway was to try to honor learner preferences, but then other strategies could include boundary setting. If terminology is used that’s offensive and perhaps well-intended, offering substituted language, just simply redirecting to focus on clinical care can be important, if learners wanted to debrief as part of their explicit preferences and making some time for debriefing and interaction afterwards. All learners don’t necessarily want that, it really depends on the person. But we have a lot of sample language from our participants in the appendices of our study that can be very helpful to folks if they want to check it out.
Tasha Wyatt
So one of the things that I noticed is, I think I gathered this, that all of the examples in the patient scenarios were around racism. Am I right in that?
Meghan O’Brien
Some of them were also around wearing a dastar was one of them. There was gender as well. We didn’t encompass all microaggressions, but we did gender, a physical appearance, and race.
Tasha Wyatt
I was wondering, just as a team, have you thought about different strategies that faculty might use depending on the different type of microaggression? Are there any clues or thoughts that you might have that it would shift depending on what the situation is?
Meghan O’Brien
We didn’t get that granular in terms of the identity being targeted. It’s a good question, and I think certainly familiarity with different types of microaggressions that target different identities is important. But in the instance of a microaggression, we’re being called to weigh different intersecting socially conferred power hierarchies in a split instance as well as consider student preferences and how do we preserve the therapeutic alliance with patients? So I think if we introduce an expectation of thinking about what type of microaggression is this, what identity is being targeted, I think the calculus gets very complex.
I think my response to a microaggression might be very different than another person’s response to the same microaggression just depending on style. I find that, for example, I can use humor to boundary set and redirect, and other people may not be able to do that as comfortably. So I think a key takeaway is that there’s a huge spectrum of responses that people find effective, and it’s hard to be prescriptive. I think the thing that is most effective is the thing that works for you and feels most natural, because when you’re in that freeze moment and you have to get the wheels turning, you need to do what feels most accessible and is also effective. But I’m curious if others have had experiences where you feel like microaggression response aligns along the identity targeted.
Javeed Sukhera
Yeah, I think a big source of tension here, though, is for various reasons, not everybody’s going to be able to do a pre-brief or be comfortable in disclosing. In our context, we’ve looked at some things around previous implementation and a lot of times, staff and people who are lower on the hierarchy or who might have minoritized identities say, “What has the organization done to create trust for me before I can bring myself into this space?” So I think that that does challenge some of how we’re approaching things around issues of bystander training because it has to be with informed consent.
So at the same time, and I think this is part of what I read through in your paper, simply saying something like, “I don’t even know what to say about this, but I wanted to let you know that I’m here to support you,” can still be powerful in terms of role modeling, intellectual candor, emotional vulnerability, in setting up the learner to be sensitized to a validating response in the face of something that might be invalidating. So I wonder what insights we might have around those types of situations where people aren’t comfortable doing or participating in a pre-brief from your work.
Meghan O’Brien
Pre-briefs, in some ways, can even be damaging if we elicit preferences and then don’t follow through on acting in alignment with those preferences, so we have to be really cautious. It’s not enough just to ask, “What do you want?” It has to be coupled with action and a independent self-generated pursuit of skills development. I think in clinical learning scenarios, at least in my context, which I recognize is not everyone’s context, I work with learners for at least a week at a time on the clinical wards. So a lot of what’s happening is building relationships, and responding to microaggressions is inherently an interpersonal response. It’s happening in the larger structure of medical education and of clinical environments. Those structures may not be equipped or prioritize responding to microaggressions or other acts of identity-based violence, and that can really erode trust.
I think as you described, one of the perils of microaggressions is that they’re really isolating. So recognizing that we’re each on our own learning curve to developing the skills to be able to respond to microaggressions effectively and skillfully. I think a foundational component is just saying, “These happen, they’re harmful.” You can name and acknowledge an experience that others might have so they’re feeling less alone. You can clarify your intent and also acknowledge that if you’re not the best person to offer support in that environment for whatever reason, there’s many channels of support.
So I think anything that you can do to address the isolation that results from a microaggression while continuing to pursue your own skills development to be an effective responder and while demonstrating humility to garner trust and honor that trust and preserve that trust, I think that can be one way of approaching a pre-brief. But I think we do have to be careful that if we … we can’t just ask for people’s preferences and then not respond and honor what those preferences are in a way that honors the humanity and the integrity of the people who we’re asking for vulnerability from. So I think also the reciprocal vulnerability piece is important there too. Not just asking someone else to be vulnerable, but we are offering our own vulnerability as well.
Tasha Wyatt
So as an educational researcher, I am thinking about subsequent studies in different areas where you could move into. I was just wondering as a team if you’ve thought about that and if you could give us a few hints as to what direction you’re going to take this work.
Meghan O’Brien
Yeah, it’s a great question. I think our team is a bit scattered at different institutions right now. I think one question is we’re looking at faculty experience responding to microaggressions, which doesn’t translate into what … it doesn’t necessarily actually reflect what their actual behavior is in the instance of microaggressions, right? So is there a way to assess that in the learning environments? One of our themes of acting to identify and as a springboard for identifying objectives that might be used for training, do those objectives help faculty prepare? I think would be another question. Then what’s the impact on the learners of pre-briefing and actual response to microaggression? So those are just some questions that are percolating, but we haven’t generated momentum in any particular direction as of yet.
Tasha Wyatt
Yeah, and forgive me if this was in your paper because I don’t recall it at the moment, but how did the students identify these faculty members? What was the research process around that identification?
Meghan O’Brien
We did two studies. The first study was of students’ experience and desires for faculty response when patients microaggressed the students. That was led by Dr. Justin Bullock and actually grew out an experience where Dr. Bullock and I worked together on a clinical team when he was an intern and I was his supervising attending. Every person on the team had some visible identity that was targeted by microaggressions at some point. So we did a lot of responding to microaggressions, whether that was responding in the moment or a team member making time for a debrief or another team member sending out tips on responding. One of the students during our time together shared with us that actually some of those after the occurrence responses were not helpful, and actually we were re-traumatizing. They happened at a time when he didn’t want to reengage with the event.
So Dr. Bullock and I were debriefing this ourselves and said, “Okay, well what’s happening in the literature? What do students actually want from faculty?” We couldn’t really find much. So that led to our first study where we recruited third- and fourth-year medical students, presented them four interpersonal microaggression scenarios, the same scenarios that we use for our faculty study. We asked them what they would want from faculty in these moments. It came out, one of the major themes was they wanted these preemptive conversations, these pre-briefs. As part of that study, we said, “Okay, well which faculty are doing this really well?” So we just simply asked them, those student participants who they identified, and then we purposively recruited them to our faculty study in addition to our general call for educators in the Department of Medicine and Surgery, who I think were also skewed towards being skilled just by virtue of their interest in this topic and education.
Toni Gallo
So we’re just about at the end of our conversation here. I want to give each of you a chance if you have any final thoughts that you want to share with our listeners. I’m hoping you can also touch on this idea of trust, which actually has come up in all of the conversations about the RIME papers this year, whether it’s in learner trust in the handover process with the intentions of their institution or trust between learners and learning versus evaluation and how that looks with faculty. Then trust has come up here in our conversation again today. So any general final thoughts that you want to share, and then maybe if you can touch on that theme of trust that’s come up again today, that would be great. Meghan, we can start with you.
Meghan O’Brien
This work was really engaging for me, and I learned a lot in the process of doing it. I think seeing how this translates into the real world will be an interesting question. Really making good on our responsibility as faculty do our own skills development such that we can respond to learner preferences that are shared with us, which is an act of trust, I think that’s our work as faculty. I think we can support each other in that skills development. Trust is earned. We have to demonstrate that we are undertaking the work ourselves so that we can safeguard the learning environment for our learners.
Javeed Sukhera
I think this work is another example of how, despite the proliferation of interest in expanding and addressing equity and justice in medical education, we can’t just do that in a superficial way. There’s a messiness, at times a beautiful messiness, that is part of our implementation when we actually try to implement and co-create a different way of approaching things and the norms that exist today. Work like yours and your teams provides a roadmap. But I hope that it inspires others to take a deeper dive into these cultural, structural issues, because any educational intervention can’t just be implemented in a singular way without better understanding how it sticks and is sustained.
I think the question of trust really comes back to me as something that has to be intrinsically mutual. This work, other work by folks like Tasha as well, highlight that all of our vulnerability, all of our pain, especially at a time like this in the world, it’s all interconnected. There’s a mutuality to trust. To trust one must be willing to be trusted. To trust one must really tap into experiences of mistrust and the pain and invalidation of that. It’s not one side versus the other. It’s not a zero sum. It’s really being able to hold both in each hand.
Tasha Wyatt
As I think about your paper, I think about how medicine has been developed around the biomedical model for centuries and how we’ve been very focused not on the person, but on the disease and the damage that has done to patients, to learners, to faculty. Now that we are starting to acknowledge that students are knowledge sources, that they do have their own information that’s valuable and legitimate in the clinical space, this sense of trust is developing. So we’re bringing back the kinds of humanity that I think for the last 30, 40 years we’ve been writing about and hoping would show up, but it’s actually showing up now with this shift. So I’m very inspired by this work and the work of others that are recentering what really matters and should be thought of as important and meaningful in medical education.
Toni Gallo
I want to thank you all for being here today for this great conversation, and I want to encourage our listeners to look for Meghan’s paper and for all the papers in this year’s RIME supplement. They’re available to read for free on academicmedicine.org. Definitely also check out the archive for this podcast. The other two episodes in this year’s RIME series are available to listen to now if you have not yet.
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