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22 Promoting Diversity, Equity, Inclusion andAnti-oppression (DEIA)
227
tion partner, and approximately 4hours/week of additional
homework. We have repeated this facilitator training annually, inviting new facilitators to join the facilitation team
every year as our caucusing program has grown.
Structure andLogistics ofCaucusing
The department allocates 2hours of department-wide time
every other month for anyone in the department, including
clinicians, researchers, administrative staff and residents, to
participate in caucusing. Residents are automatically
enrolled as part of their curriculum. Securing coverage from
hospital rotations for residents is not always feasible, though
faculty members often cover resident duties so that they can
attend.
The initial caucusing groups were formed based on the
demographics of volunteer facilitators and included White
groups, a Black group, and Non-Black POC groups. By the
second year and with departmental feedback, these groups
were restructured to include White groups, a Black group, a
Latinx group, Asian and Pacic Islander groups, and a group
for individuals identifying as Mixed, Indigenous, Middle
Eastern, or North African (MI-MENA). These groupings are
still clearly imperfect–the MI-MENA group only exists
because we have such small numbers of department members with those identities, highlighting the potential for
hypermarginalization in some communities. Additionally,
there is clearly diversity within each of the racial afnity
groups and much of what we discuss and process in caucusing is the different experiences we have within our groups.
Each caucus is divided into subgroups so that each group is
no larger than 20 participants with a goal of no more than 12,
though this is limited by facilitator availability. We currently
have over 100 participants in caucusing. Consideration is
given to power dynamics based on institutional positionality,
and efforts are made to avoid placing supervisors in groups
with their direct reports whenever possible. We deliberately
mix trainees, staff, and faculty in the caucus groups so that
we can use the caucusing space to address some of the power
dynamics that arise in those relationships and build relationships that help bridge those differences.
Each month the facilitator group meets to plan the curriculum and content for the next caucus session. Facilitators
meet as a whole group to begin planning and in the following
weeks break off into racial afnity groups to hone the session
for their group. Every group is facilitated by a dyad of facilitators so that they can support each other and hold themselves accountable. After every caucusing session, the whole
facilitator group meets to share and process the session with
one another. Caucus facilitators are available between caucusing sessions to support participants in their groups.
Overview ofCurriculum
The caucusing curriculum evolves every year based on feedback from the prior year and goals set by the caucusing community. Topics covered have included:
• The origins of race and racial socialization
• Internalized racial oppression and stress
• Behavior patterns that perpetuate internalized racial
oppression
• Microaggressions and white body supremacy
• Intersectionality
• Horizontal hostility
• Somatic experiencing of racial trauma
• How medicine and our department contribute to IRO
• BIPOC savior complex and white savior complex
• Examining our own patterns of power hoarding and harm
• Naming and repairing harm
• Processing and responding to action alerts
• Connection, fellowship, and care within the group
Assessment
Because this is a new program, it has been important to integrate an annual assessment survey into our planning and to
present program outcomes to the entire department each
year. Our data provide transparency and accountability
within our department. Overall, participants have rated their
experience with caucusing positively and describe applying
skills they learned in caucusing regularly during their
workday.
Vision Forward
The number of participants in the caucusing program has
grown every year, and we anticipate continued growth.
Because residents rotate in many clinical areas that are not
within our department we have begun inviting key partners
in other parts of the hospital to join our program. This
requires building an ever-growing and ever more diverse
community of facilitators. A fully realized caucus structure
would allow for the separate caucuses to come together and
share across groups. In the rst few years of caucusing, there
was enough of a history of racialized harm and not enough
racial literacy that it was clear we would do more harm than
good by bringing groups together for cross-racial dialogue
on that scale. As we enter our fourth year of caucusing, our
hope is to begin holding large-group report outs in the near
future. As race-based caucusing becomes more established,
we anticipate it will inspire and support other types of afn-
228
D. Coa et al.
ity group to allow exploration of a broader range of identities. These groups could form as need arises and determine
their periodicity and curriculum based on need. For example,
a department-wide Jewish afnity group launched in 2023
to explore intergenerational trauma and its impact on
solidarity.
Handling Microaggressions
In the spirit of transparency, it is important to acknowledge
that we have not consistently addressed microagressions and
bias effectively when they were reported to us. In a department that takes pride in its commitment to social justice,
people can be uniquely defensive when receiving feedback
about microaggressions, and a good/bad binary can develop
that promotes shame when people make mistakes. We have
had to work deliberately against this to allow ourselves to
grow. In order to maintain a safe and inclusive community, it
is important to move beyond simply supporting people when
they experience microaggressions to taking action and making change in response to them. Like most health systems, our
university has a reporting system for harassment and microaggressions, but the timeline for response, insufcient transparency, and the high threshold for action have meant that
frequently residents prefer to discuss their experiences with
faculty. For that reason, we work to ensure that every resident
has access to mentors and advisors who have concordant
identities with whom they can process and strategize around
their experiences. Faculty members assume responsibility not
only for helping residents process their experience but also
for, with their permission, working with the person or service
that caused the harm to prevent it from happening to others.
This follow-up, with closed-loop feedback to the resident
afterward, is important for building trust and making change.
Residents may struggle to believe that reporting negative
experiences will be anything but harmful to them. To help
build trust early on, we have a “Truth Telling” session in orientation where we share with them honestly about the current state of our learning climate. In this session we discuss
which rotations we have heard complaints about, what efforts
we are making, and where we are still stuck. The session also
emphasizes that program leadership is open to feedback,
humble in our efforts, and committed to making the learning
environment more inclusive and less harmful. Additionally,
all residents have one on one meetings with members of the
faculty to discuss the session, share how their identities have
impacted past experiences in training and discuss what they
currently need in their training.
A similar practice, called the prebrief, can be used in the
inpatient setting when a team is rst forming [22]. The
attending or senior resident introduces the fact that microaggressions may occur and asks team members what type of
action or support they would like in response if they do.
These early invitations to dialogue allow us to hear much
more readily about critical resident experiences.
One of our as yet unachieved hopes is to create a reporting
system within the residency program that has a lower threshold for action than the university system and utilizes a restorative justice or transformative justice approach. Many
medical institution’s reporting structures are geared toward
punishment or discipline for those who have caused harm,
and we seek instead to build an approach centered on learning together.
Reducing Bias inEvaluation ofLearners
Subjective evaluations of learners are inuenced by implicit
bias [23]. In response, ACGME has required residency programs to shift to more “objective” measures of trainee performance, such as test scores, milestones, and entrustable
professional activities (EPAs). Implementation of milestonesbased assessment has reduced, but not eliminated, racial bias
in assessments [24]. Diversifying the Clinical Competency
Committee (CCC) and explicitly discussing the impact of
bias in CCC meetings can help mitigate this. In our own residency program, we are working to strike a balance between
ensuring that residents have sufcient concrete feedback
while also ensuring that they have freedom to dene their
own goals and are not stied by a sense of constant scrutiny.
That sense of scrutiny can be particularly burdensome for
URM residents. Our current strategy for addressing this is
inviting residents to develop a self-driven learning plan with
their advisor prior to a CCC meeting and having the advisor
present that learning plan to the CCC, effectively bringing
the residents’ priorities and voices into the meeting. Other
residency programs invite residents to participate in their
CCC reviews, which is an excellent way to ensure their perspective is included. Our own residency is currently in the
process of overhauling our assessment and feedback strategies, as residents report that they do not receive adequately
concrete, actionable and timely feedback. This lack of concrete feedback can be particularly destabilizing for residents
who are not sure if they belong or are valued because of their
marginalized identities.
Financial Investment
In addition to making the unprecedented investment in racial
afnity group caucusing, it is important to emphasize that
this effort alone is not enough to improve upon existing
departmental harms and biases that are prevalent in medicine. Racial caucusing is indeed a vessel to allow for a collective deepening of our racial literacy, but it does not address
22 Promoting Diversity, Equity, Inclusion andAnti-oppression (DEIA)
229
policies and cultural norms that could be contributing to
inequitable conditions. Making those changes requires signicant departmental investment.
In 2018, our department chair appointed an inaugural
Vice Chair of Diversity. At the time, there was momentum
for integration of DEIA into the fabric of leadership teams
everywhere, powered largely by social justice advocates
raising awareness of the tragic murders of Black men in
America at the hands of law enforcement. Groups like White
Coats for Black Lives were an inspiration that nudged departmental and school of medicine leadership to begin to create
leadership roles focused on how to integrate DEIA principles
into the medical education communities. There are real benets to having a DEIA leader involved in departmental leadership discussions, engaging in strategic planning for DEIA,
and elevating the importance of DEIA to the same level as
other core domains such as education and research.
At the same time, it is important to acknowledge the limitations of this approach. Having a solitary leader in charge of
the departments DEIA is aligned with hierarchical processes
and makes it difcult to gather collective input. DEIA committees who do provide input are often volunteers, contributing to minority tax in the department. It takes more than a
small amount of one person’s time to integrate DEIA into an
entire department. A team that includes faculty and staff, as
well as a trained DEIA expert who can devote their full time
to this work, is likely to be more successful than the traditional model of a DEIA lead physician with a small amount
of time carved out for the role. Advancing equity, inclusion,
diversity, and anti-oppression requires durable nancial
investment from the department.
Principles forDismantling Racism inMedical
Education
It is essential to remember that faculty behavior is just as
instructive as any content they teach. Faculty members
model the patience, compassion, curiosity, and courage they
would like learners to practice. The following are key concepts and commitments for faculty and leadership to embody
when integrating antiracism into residency education. This
list is taken from the UCSF Anti-Racism and Race Literacy
Toolkit [10]
• Racism affects all of us.
• Dismantling racism is everyone’s work.
• In fact, dismantling racism is especially the work of those
who hold white/race privilege.
• Take responsibility for “doing the work.”
• Cultivate a culture of trust, humility, accountability, and
self-care when talking about race.
• Approach conversations about racism with a growth
mindset.
• Be prepared to be uncomfortable during productive dialogue. If you experience discomfort or anxiety that comes
from a place of unfamiliarity when talking about race,
approach your discomfort with inquiry.
• Use your own mistakes as a transparent learning session.
Apologize and recognize why what you said or did was
painful or ignorant. Openly discuss the mistake you made
and what biases reveal in your own self. The model that
it’s ok to make mistakes; what’s most important is what
we do afterward.
• Some useful phrases include:
– What I am hearing from you is…
– I am sorry I did that. Thank you for letting me know
how that impacted you and for the courage it took to
tell me.
– It seems that…. Is that true?
• Be present. Don’t just plan what you’re going to say next.
You are allowed to think after someone speaks, and it
models thoughtful behavior for others to emulate.
• Continue to read, reect, and seek additional training!
Review common terms to ensure shared understanding.
• Avoid frameworks of colorblindness.
• Guilt and defensiveness can make talking about racism
difcult. Keep trying.
• Be a co-conspirator against racism!
Recommendations toStay Current
Family medicine residency leadership must stay abreast with
the dynamic culture of DEIA.Perhaps like no other interest
area in medicine, DEIA champions are the leading voice in
humbly acknowledging that we do not have all the answers
in this area and that is exactly where we should be. It is up to
family medicine to lead by example by emphasizing that
DEIA work is a journey. Although we all are at different
stages, the work never ends. We still fall short, and want to
emphasize, to ourselves and others, that creating an environment conducive to feedback is not sufcient. We must also
create an environment committed to active change.
References
1. Stevens GG. Family medicine as counterculture. Fam Med.
1989;21(2):101–9.
2. Gutierrez C, Scheid P, The history of family medicine and its
impact in US Health Care Delivery. UCSD Department of FPM.
https://www.aafpfoundation.org/content/dam/foundation/documents/who- we- are/cfhm/FMImpactGutierrezScheid.pdf. Accessed
2 Feb 24.
3. Nelson A. (2011). Body and soul: the black panther party and
the ght against medical discrimination. University of Minnesota
Press. http://www.jstor.org/stable/10.5749/j.ctttt9qf
4. AAMC. Diversity in medical school admissions. Updated
November 2023. https://www.aamc.org/about- us/mission- areas/
medical- education/diversity- medical- school- admissions
230
D. Coa et al.
5. Jetty A, Jabbarpour Y, Pollack J, et al. Patient-physician racial
concordance associated with improved healthcare use and lower
healthcare expenditures in minority populations. J Racial Ethn
Health Disparities. 2022;9:68–81. https://doi.org/10.1007/
s40615- 020- 00930- 4.
6. Sharma A, Angel L, Bui Q. Patient Advisory Councils: giving
patients a seat at the table. Fam Pract Manag. 2015;22(4):22–7.
7. Donsky J, Villela T, Rodriguez M, Grumbach K. Teaching
community- oriented primary care through longitudinal group projects. Fam Med. 1998;30(6):424–30. PMID: 9624521.
8. Schiefer R, Levy S, Rdesinski RE, Garvin RD, Verdieck A,
Skariah JM. Impact of a residency family systems curriculum
on the postresidency practice of family physicians. [Published
September 12, 2023]. Fam Med. 56:35. https://doi.org/10.22454/
FamMed.2023.411218.
9. Saba GW, Villela T, Goldschmidt RH.Behavioral science rounds:
identifying and addressing the challenging issues that residents face
on a family medicine inpatient service. Fam Med. 2019;51(7):603–8.
https://doi.org/10.22454/FamMed.2019.726006.
10. Meghan O’Brien, Rachel Fields, and Andrea Jackson, with support
from UCSF Differences Matter Working Group 3. Anti-racism and
race literacy: a primer and toolkit for medical educators. June 2022.
https://medschool.ucsf.edu/differences- matter/action- groups/
focus- area- 3
11. ACGME. Equity matters holistic recruitment toolkit https://
dl.acgme.org/learning- paths/acgme- equity- matters- holisticreview- toolkit. Accessed 2 Feb 2024.
12. Ely K, Lagasca G, Andersen S, Patel D, Simanton E.Medical students’ socioeconomic status and academic performance in medical school. Cureus. 2023;15(6):e39875. https://doi.org/10.7759/
cureus.39875. PMID: 37404444; PMCID: PMC10315161.
13. Edmond MB, Deschenes JL, Eckler M, Wenzel RP. Racial
bias in using USMLE step 1 scores to grant internal medicine
residency interviews. Acad Med. 2001;76:1253–6. https://doi.
org/10.1097/00001888- 200112000- 00021.
14. Fang D.Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284:1085. https://doi.org/10.1001/
jama.284.9.1085.
15. Teherani A, Hauer KE, Fernandez A, King TE, Lucey C. How
small differences in assessed clinical performance amplify to
large differences in grades and awards: a Cascade with serious consequences for students underrepresented in medicine. Acad Med. 2018;93:1286–92. https://doi.org/10.1097/
ACM.0000000000002323.
16. Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A,
Moore EZ.Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations. PLoS
One. 2017;12(8):e0181659. https://doi.org/10.1371/journal.
pone.0181659. Editor: Jeffrey A.Gold, Oregon Health and S.
17. Mullan F.White coat, clenched st: the political education of an
American physician. NewYork: Macmillan; 1976. Print.
18. Heather Macdonald R, Beane RJ, Baer EMD, Eddy PL, Emerson
NR, Hodder J.Accelerating change: the power of faculty change
agents to promote diversity and inclusive teaching practices.
J Geosci Educ. 2019;67:330–9.
19. Sgoutas-Emch S, Baird L, Myers P, Camacho M, Lord S.We’re not
all white men: using a cohort/cluster approach to diversify STEM
faculty hiring. Thought Action. 2016 Summer;32(1):91–107.
20. Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA.
2000;284(9):1085–92. https://doi.org/10.1001/jama.284.9.1085.
PMID: 10974686.
21. Crossroads Ministry. Racial identity caucusing: a strategy for
building anti-racist collectives. https://crossroadsantiracism.org/
wp- content/uploads/2020/08/Racial- Identiy- Caucusing- Strategy.
pdf
22. Bullock JL, O’Brien MT, Minhas PK, Fernandez A, Lupton KL,
Hauer KE. No one size ts all: a qualitative study of clerkship
medical students’ perceptions of ideal supervisor responses to
microaggressions. Acad Med. 2021;96(11S):S71–80. https://doi.
org/10.1097/ACM.0000000000004288. PMID: 34348373.
23. Arora VM, Carter K, Babcock C. Bias in assessment needs
urgent attention – no rest for the “wicked”. JAMA Netw Open.
2022;5(11):e2243143. https://doi.org/10.1001/jamanetworkopen.
2022.43143.
24. Gray BM, Lipner RS, Roswell RO, Fernandez A, Vandergrift JL,
Alsan M. Adoption of internal medicine milestone ratings and
changes in bias against Black, Latino, and Asian internal medicine residents. Ann Intern Med. 2024;177(1):70–82. https://doi.
org/10.7326/M23- 1588. Epub 2023 Dec 26. PMID: 38145569.
Developing aHealthy Learning
Environment
KimberleyMiller, ErinO’Connor, andBarbaraWolf
23
Key Points
• Psychological Safety is the shared belief among individuals as to whether it is safe to engage in interpersonal risktaking in the workplace, i.e., one in which employees feel
safe to voice ideas, willingly seek feedback, provide honest feedback, collaborate, take risks and experiment.
• Taking a “Just Culture” perspective can promote
Psychological Safety within residency programs, thereby
increasing openness to acknowledging missteps and using
the experiences to inform learning.
• The sense of Psychological Safety within a residency can
be developed through building trust with medical learners. Mindfulness of positionality, transparency, normalizing not knowing, and use of probing questions are
strategies to promote trusting relationships.
• Feedback is an integral part of residency experience with
its aim being to improve the performance of learners. The
effectiveness of the feedback in doing so is inuenced by
factors at multiple levels. On the microsystem level, how
the feedback giver (FG) communicates the feedback and
how the feedback receiver (FR) approaches the feedback
both share responsibility for the effectiveness of the
feedback.
• Implicit bias is a form of bias that occurs automatically
and unintentionally, that nevertheless affects judgments,
decisions, and behaviors [27].
• To avoid implicit biases interfering with healthy learning,
an approach emphasizing identication and combating
implicit biases through self-reection and mindfulness
ought to be utilized.
K. Miller (*)
Family Medicine Residency, Lutheran General Hospital under
Advocate Health, Park Ridge, IL, USA
e-mail: Kimberley.Miller2@aah.org
E. O’Connor · B. Wolf
Behavioral Medicine Education, McLaren Flint Hospital,
Flint, MI, USA
• High-level questioning at the micro-level and procedures
at the macro-level are some strategies to promote effective and equitable teaching practices in medical residency
education.
• A foresight approach to identication of struggling medical learners and preemptive remediation in Design
Thinking promotes a culture of a healthy learning environment and the ultimate success of learners.
Developing aCulture ofLearning
withPsychological Safety
The Accreditation Council for Graduate Medical Education
(ACGME), in its 2022 annual Clinical Learning Environment
(CLER) report, noted the following effects of the COVID-19
pandemic on learning:
1. Few clinical learning environments appeared to
have a long-term strategy to address multiple
system- level factors that impact the well-being of
the clinical care team; most clinical learning environments were primarily focused on individual
resilience.
2. The COVID-19 pandemic had a unique impact on
residents’ and fellows’ well-being with regard to
their readiness for future practice.
3. The disruptions associated with the COVID-19
pandemic were anticipated to have a long-term
impact on faculty member workload and well-being
[18].
It seems clear that burn out among attendings, fellows,
and residents has increased since the COVID-19 pandemic
began. Burnout levels among physicians in 2019 stood at
45%, a rate which was concerning to many. However, by late
2020, the rate of burnout had increased to 50% then further
increased to 62% by 2021 [23]. Interestingly, the level of
chaos and the sense of control were signicant contributors
to burn out. Those settings in which chaos was less promi-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_23
231
232
K. Miller et al.
nent and where clinicians had a sense of their own agency
had lower rates of burnout [23].
Years of research have shown that reasons for burnout are
multivariate, including not enough time with patients, too
much time spent on administrative tasks, electronic medical
records that require too many clicks, too little authority at
work, and lack of time with family and friends [46]. ACGME
also tracks in their annual surveys the residents’ responses to
inquiries concerning fear of retaliation for speaking up and a
workplace setting that does not encourage learners to voice
their concerns. Often, residencies that are struggling may
show decreases in these scores in the annual survey.
Residencies anecdotally describe a struggling learner as a
bad resident or a learner in need. It may be one whom nurses
complain about, other residents whisper about, or attendings
complain to the program director about regarding their
behavior. These residents may be already in a performance
improvement plan or probation or have had no intervention
or feedback. The feedback from the Clinical Competency
Committees (CCC), which generally meets twice a year,
may be the rst time a resident learns that they are in trouble
[18].
The concept of psychological safety was rst utilized in
the business world in the late 1990s where continuous
improvement mechanisms incorporated the concept as a way
to improve processes through behaviors where learning can
increase [7]. Edmondson’s original denition is still the gold
standard: psychological safety is the shared belief among
individuals as to whether it is safe to engage in interpersonal
risk-taking in the workplace, i.e., one in which employees
feel safe to voice ideas, willingly seek feedback, provide
honest feedback, collaborate, take risks, and experiment [8,
9].
In a psychologically safe learning environment, staff, residents, fellows, and attendings would feel free to voice their
thoughts about a patient, make suggestions regarding
improving a process, provide each other with feedback, and
develop trusting, supportive relationships, providing a buffer
against burnout, and promoting a healthy learning environment. Disagreements can become avenues for considering
disparate opinions, rather than taken as personal attacks.
Competition may decrease, while cooperation and collaboration can increase.
The process of becoming a physician and the hidden curriculum in medicine have often created an atmosphere that is
the opposite of psychological safety. For example, if a student wants to get into medical school, the competition for the
best grades, the best SAT scores, the highest MCATs, and the
most research accomplished becomes the way for both promotion and approval. While the published curriculum
emphasizes developing and increasing compassion for
patients during training, the hidden curriculum may identify
patients by disease or room number rather than as an individual, permit denigration of some specialties over others,
emphasize positionality, or perpetuate implicit biases.
Negative comments such as “Didn’t you learn that in medical
school?”, “I can’t believe you don’t know that,” or “What
kind of senior are you going to be?” can quickly silence a
learner. Too, a blame-focused sensibility to the learning environment can quickly teach learners to answer only if they are
sure they are correct. Such an atmosphere ultimately hinders
learning.
The model of teaching which believes that stress and
tiredness are part of medicine and the learner must accept
thisstill holds sway in some quarters. Commonly heard in
discussions are phrases such as “I had to do it, so they should
too” or “Residents these days are so spoiled, we didn’t have
80 hour per week limits when I was training.” Evidence tells
us that learning is harmed when lack of sleep and too much
unrelenting work is the experience of the learner. Memory
deteriorates and symptoms of burnout can increase medical
errors [15].
If a leader takes an authoritarian, unsupportive, or defensive
stance, team members are more likely to feel that speaking up in
the team is unsafe. In contrast, if a leader is democratic, support-
ive, and welcomes questions and challenges, team members are
likely to feel greater psychological safety in the team and in their
interactions with each other [28].
The idea that inclusive leaders facilitate an invitation and
appreciation for others’ ideas and suggestions rather than
negating said suggestions is at the core of psychological
safety in hospital settings. This can be particularly important
for attendings, resident physicians, medical students, and for
further collaboration.
The concept of just culture was developed in the years
following the seminal Institute of Medicine (IOM) study To
Err is Human, Building a Safer Health System. This landmark study found up to 90,000 deaths per year are due to
medical errors. Since the study’s publication, healthcare systems throughout the country have focused on patient safety
as a primary initiative. Just culture suggests that when medical errors are revealed, it is generally considered an issue
related to a systems problem and that understanding the error
from a root cause analysis point of view can deter further
similar errors. Mistakes are assumed to happen (To Err is
Human), and by understanding this, blaming an individual is
short-sighted and decreases psychological safety. Indeed, an
unsafe work environment hides mistakes and limits the
opportunity for learning. Taking a just culture attitude into
residency teaching would increase psychological safety and
a psychologically safe residency would assume mistakes are
how we learn.
23 Developing aHealthy Learning Environment
233
How can residencies increase psychological safety?
1. Begin with the attitude that residents are honest brokers
in the relationship. This means they are resilient and hardworking and in residency to learn.
2. Discard the idea that there are good residents and bad
residents. Residency is difcult for everyone and at times,
each person needs added support.
3. Faculty can develop an increased awareness of their own
implicit biases about residents.
4. Everyone can begin by asking, ‘Tell me more, how are
you understanding this problem/patient?’ and then listen
with awareness.
5. Training in communications and conict resolution can
increase skills for all learners and faculty.
6. Learn about increasing self-awareness through mindfulness and/or emotional intelligence training.
7. Bring the subject of psychological safety to small groups
for discussion.
Building Trust
Building on the important concepts discussed related to psychological safety, there are some additional considerations
related to building trust with learners to promote a healthy,
psychologically safe learning environment.
Positionality
Positionality refers to where one sits within a social construct, including how they are perceived and affected by
issues of power, communication, and other interpersonally
meaningful interactions [37]. Awareness of positionality
within a system is crucial to building and maintaining trust
within a family medicine residency given the hierarchical
nature of medicine. Positionality maintains that one’s identity is shaped by social constructs which affects one’s outlook on the world. Understanding that outlook can be an
important part of identifying and combating implicit bias [4].
Positionality not only impacts one’s behavior in terms of
actions and responses to others; but maybe more importantly,
it can impact how one is perceived by others. This can be
difcult to remember or fully appreciate, especially for new
faculty who are used to being in the resident/trainee role.
Constructive feedback delivered by a faculty member may
carry more weight than it did when it was peer-to-peer feedback. Being mindful of interactions with residents, with
positionality in mind, may help to consider not only the content of the message but also the context and manner in which
it is delivered and how it may be perceived by the receiver.
Several strategies discussed below can assist with this.
Set theStage
Prior to any work with a resident, it can be helpful to sit down and have a discussion related to expectations, including both faculty and resident expectations. By establishing and discussing these expectations with the resident, the relationship begins on a note of transparency and security as the resident can learn what to anticipate. Setting the stage discussions can include a range of topics, including everything from the physical environment (i.e., where the restrooms are, where they can nd clean water and a space to take a break, where to locate the call or work rooms) to the frequency and manner in which feedback will be provided. Of utmost importance is communicating to the resident that feedback will be frequent and abundant. This is likely to reduce any concern over time that thefeedback is given because of underperformance, and instead allows for a pre-emptive normalization of feedback as merely another part of the learning experience. Setting expectations at the beginning of a learning experience also helps faculty when it comes time to give particularly tough feedback or initiate a performance improvement plan. Referring back to the initial Set the Stage conversation can remind the resident of the expectations that were clearly communicated to them so that discrepancies can be highlighted and justication made for any necessary corrective course of action. Trust is developed through the transparency in these expectations, but also in the consistency of how each person upholds these expectations. i.e. A faculty advisor develops trust with the resident by explaining that their discussions will largely be between them but if there are concerns impacting patient care or their performance in the program, that would be shared. They maintain trust by upholding that promise.
Normalize Not Knowing
It should be every faculty member’s expectation that their
residents do not know everything. Residents entering into
their training do so under the assumption that they have
much to learn about medical knowledge, patient care skills,
other ACGME competencies, and the eld of family medicine. Even beyond training, it is a widely accepted notion
that medicine requires lifelong learning [30]. However, residents can experience heightened anxiety and pressure to perform, leading to unrealistic expectations of perfection. This
unhealthy perfectionism may manifest behaviorally in several ways, from overcompensating in terms of time and
energy devoted to work to signicant withdrawal and lack of
participation in required residency-related activities [40].
Informing residents that they are not expected to know everything and sharing options that they might have when they
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nd themselves in a situation of not knowing, encourages
learners to be transparent with their knowledge gaps and
develop a trusting relationship with faculty. Finally, modeling that not knowing is normal can have a profound impact
on learners, and demonstrate the value of life-long learning
that denes family medicine. When rounding on the medical
oors, the medical team might encounter a very rare condition that even the faculty attending has not had much experience with; acknowledging, “This is not something that I see
very often, so I’m not entirely sure of all the diagnostic components. Let’s look them up together to make sure we have a
thorough understanding.” Again, this normalizes not know-
ing, even for faculty, and also models how to nd the information necessary to provide optimal clinical services. Some
suggestions for statements normalizing not knowing, or
incorrect responses, could include:
• “Many folks think the same thing, but actually. . .”
• “Take a guess at why that might be the case . . .”
• “I don’t expect you to know XYZ, but I’m curious, what
do you think causes XYZ?”
Probing, Not Prodding
In medical education, the way in which a teacher assesses a
learner’s understanding can either encourage trust and communication or can lead to avoidance and fear of confrontation [29]. Historically, medical students and residents had
been subjected to inappropriate and unhelpful teaching techniques, sometimes referred to as “pimping” [5]. Thankfully,
now the eld has come to recognize that more strengthsbased and positive methods of inquiring about a resident’s
understanding of a topic, as well as using questions to help
guide them to the correct answer, not only improve critical
thinking but also maintain the safety of the relationship. This
can be thought of as Socratic questioning or purposeful questioning [19]. The intent, tone, timing, and context are all
important.
Dr. Shannan was one of the chiefs in our family medicine program. She was sharing a horror story with the
incoming interns about a former faculty member and
described a time when she made a pretty signicant
mistake in billing for a patient. When she consulted her
faculty physician, the faculty member exasperatedly
stated “How could you not know this?!” and took over.
Dr. Shannon laughed that she actively avoided that preceptor’s ofce and still didn’t know how to bill that
procedure.
Probing utilizes a calm, yet inquisitive, open-ended
approach to questioning, which allows the resident to elaborate on how they think about a given topic, thereby demonstrating respect and trust. The following example questions
can be used to engage in probing with residents:
• Say more about what you mean.
• Let’s see if we can explore this further…
• Help me understand your thoughts here.
Giving andReceiving Feedback toResidents
Dr. Park was a rst-year resident who was in the last
week of her pediatric rotation. Her attending that had
worked with her pulled her aside at the end of her last
day to give her feedback. He told her that she came
across as meek and he was concerned that her anxiety
would limit her professional development and ability
to connect with patients.Dr. Park wastaken aback. She
knew that when she had rst started she had been a bit
anxious as it was new for her to work with children,
but didn’t think it was more than her peers who talked
about their own anxieties, and as time went on she had
felt comfortable in her role and with the patients. She
felt ashamed, confused, and angry with the attending,
wondering if he gave the same feedback to some of her
male colleagues whom she knew to be more anxious
than her. Dr. Park reected that she is naturally intro-
verted and that she tends to listen and reect before
speaking, which may come across as quiet. By the time
she had a response to the attending’s questions, he had
moved on to the next person
In this example, the giver should have started with
clarifying how Dr. Park was feeling in her patient
interactions, exploring how she sees herself and how
she thinks others perceive her. In doing this the faculty
would may have rethought his interpretation of her
behavior, possibly identifying any implicit biases.
Rather than focusing on discussing strategies for alleviating anxiety, the faculty could have provided more
helpful feedback related to how her behaviors that are
related to introversion may be perceived by others.
Had Dr. Park claried her perspective, she could have
similarly redirected the feedback conversation. Indeed
if either, or both, had done so, each could have walked
away with a better understanding of themselves and
the other.
23 Developing aHealthy Learning Environment
235
The above example demonstrates how the approach to providing, as well as receiving, feedback impacts the outcomes
and effectiveness of the interaction. Feedback has been
dened by the Encyclopedia Britannica Dictionary as “helpful information or criticism that is given to someone to say
what can be done to improve a performance, product, etc.”
[10] Key to this denition is the emphasis on the goal that
feedback is intended to result in improvement. In the family
medicine residency training context, feedback focuses on
providing information on a performance largely related to
ACGME competencies including Medical Knowledge,
Patient Care, Practice-Based Learning and Improvement,
Interpersonal and Communication Skills, Systems-Based
Practice, and Professionalism. Faculty physicians, residents,
program directors, medical students, and staff (MAs, nurses,
front desk associates, etc.) can all be in both the role of feedback givers (FG) and feedback receivers (FR). Importantly,
Ende [11] distinguishes feedback from evaluations where
evaluations are summative in nature and completed by
reecting on an individual’s performance and determining a
score that compares how the individual performs to expectations or benchmarks or other learners. Evaluations are inherently judgmental and comparative in nature. Feedback, in
contrast, is not intended to compare to standards but rather to
provide insight into performance for the purpose of learning
and development. Both evaluation and feedback are important in medical education with distinct goals, thus both evaluation and feedback are necessary.
Feedback, when provided effectively, offers the learner
opportunities to grow professionally and increase skills.
Tavares and colleagues [38] suggest an approach called
“learning conversations” to optimize growth as a result of
feedback. Learning conversations blend the relationship,
credibility, and emotional factors, which are largely focused
on in feedback traditions, with debrieng strategies, which
focus on psychological safety and guided reection. Effective
feedback is provided in a way that it can be heard by the
receiver and not beget defensiveness, maintains the relationship between giver and receiver, and promotes ongoing
openness to feedback [32]. Ultimately, feedback effectiveness is assessed by examining how the receiver’s behaviors,
cognitions, or attitudes have changed as a result of the feedback [41]
.
Though the onus is often placed on the giver, the responsibility for assuring the effectiveness of feedback is shared at
multiple levels [2]. The program is responsible for promoting an environment of psychological safety and trust as well
as a culture of feedback. The system is responsible for providing adequate time, resources, and incentives to allow
feedback. The giver is responsible for providing the feedback skillfully while the receiver is responsible for hearing
the feedback, engaging with it actively, and utilizing it. A
common critique by residents in training programs is that the
faculty doesn’t give enough (or good enough) feedback. And
yet, faculty meetings are rife with discussions about frustration with residents who don’t seem to listen to their feedback. To quote Stone and Heen [36] “Interesting. When we
give feedback, we notice that the receiver isn’t good at
receiving it. When we receive feedback, we notice that the
giver isn’t good at giving it.”
Qualities ofEective Feedback
andResponsibilities ofGiver andReceiver
Accurate
In addition to the obvious benets to patient care associated
with accurate feedback, accuracy is also important to how
the receiver will receive the comments. Heen and Stone [45]
identied three psychological triggers (Truth, Relationship,
and Identity Triggers) that impeded a learner’s reception of
feedback. Truth triggers occur when the feedback that is
given is bad, unjust, incomplete, or unfair. Truth triggers may
cause a receiver to disregard the feedback entirely or may
cause a loss of perception of competency and respect for the
giver. Although assertive receivers may clarify the feedback,
the positionality within the medical education system discourages challenging those in a higher position on the hierarchy for most learners.
The giver has the responsibility to ensure the accuracy of
feedback by remaining up to date on research and practice
recommendations as well as making sure they are wellversed and condent in the content provided. Probing questions should be used to determine how the learner perceives
the context of the situation as well as to elicit the receiver’s
response to the feedback accuracy. Meanwhile, the receiver
has the responsibility to avoid defensiveness, ask for clarication when needed, reect upon the feedback, and provide
the giver with a response regarding the accuracy of what is
discussed.
Objective andClear
Accuracy is optimized when feedback is objective. Feedback
should be based on direct observations and focus on behaviors engaged by the receiver during this observational period.
Subjective opinions or general statements, such as describing someone as meek as in the example above,” do not provide adequate evidence to support feedback nor do they
facilitate specic strategies for remediation. Learners need to
be able to do something with feedback. When feedback is
too general or doesn’t give tutelage [16] the learner may not
know how to remediate the identied decit. As a result, they
may feel frustrated and helpless, or disregard the feedback.
Additionally, learners struggle to integrate feedback when
the focus is on a comparison to others rather than on the task
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itself [17]. Thus, by targeting feedback at the task or behavior, rather than at personality characteristics, any threat to the
learner’s self-esteem or social status can be minimized. To
promote objective and clear feedback the giver has the
responsibility to base feedback on direct observations, use a
rubric or other standardized instrument, provide specic
examples, and provide feedback directly to the individual
rather than through others. Similarly, the receiver can facilitate objective and direct feedback by asking for examplesand
requesting to be observed performing specic behaviors.
Action-Oriented andPlanful
Again, feedback has to be useful to the receiver. The receiver
should ideally leave the interaction with concrete next steps
for remediation and plans for measuring improvement. The
giver should provide specic instructions for what alternative behaviors are desired. By working with the receiver to
establish goals, learn new skills to achieve those goals, and
establish plans for practicing and assessing progress on
implementing new behaviors, the giver can help to ensure
feedback is used effectively. Likewise, the receiver must
engage in self-reection, ask clarifying questions to understand how to meet the communicated expectations, and commit to utilizing the feedback to improve performance and
track progress over time.
Recognized asFeedback
Adcroft [1] found a distinct difference between how often
educators believed that they provided feedback and how
often their students perceived receiving feedback. When faculty believe they are giving regular feedback and residents
disagree, both parties become frustrated. A pitfall of many
teachers is to be overly gentle with providing feedback to
learners. For example, feedback may be described as an area
for growth rather than an observed error or suboptimal performance. Too, the faculty may avoid a direct description of
the error to avoid discomfort or awkwardness. As a result,
the resident may not associate the feedback with their performance, may underestimate the weight of the feedback, or
may become confused about the purpose of the conversation.
Ultimately, it may become what Ende [11] terms “vanishing
feedback;” in which the giver thinks they have given feedback on a performance while in reality there was nothing
substantial transmitted or taken away.
To prevent vanishing feedback, the giver can label the
feedback as such, (i.e., “I’d like to meet to give you some
feedback about the colposcopy we did together.”), be direct
and clear and managing their own reactions and emotions
that may interfere with directness. Too, a receiver can
actively seek out feedback and clarify the intention of discussions that may be feedback that is not explicitly labeled.
Balanced andLimited
When providing feedback, the giver must balance the need
for remediation with the receiver’s feelings and the relationship. Too much negative feedback can make the receiver feel
overwhelmed and frustrated. An emphasis on recognizing
and rewarding positive behaviors encourages motivation and
helps the resident feel valued. B.F. Skinner’s Operant
Conditioning teaches us that providing rewards for a behavior increases the frequency of that behavior. Beware though
as too much positive feedback can frustrate the receiver and
degrade the value they place on feedback. The ideal praiseto- criticism ratio as described by Zenger and Folkman [43] is
5 or 6 positive comments to one critical. A common complaint in residency programs is that the attendings only put in
evaluations for the things the residents do wrong and don’t
recognize what they do well. In many cases, this contributes
to their sense of burnout and the divide between residents
and faculty. Along the same vein, when humans are inundated with too much information, attention will wane and
critical pieceswill be forgotten. Miller [25] suggests that the
limit of working memory is seven plus or minus two pieces
of new information. Thus, not only should the balance
between critical and positive be considered but the overall
quantity of feedback in one setting should also be limited.
To facilitate effective feedback, the giver should provide
80% positive to 20% critical feedback and offer no more
than 1–2 pieces of critical feedback and 5–7 points of feedback total at a time. Table23.1 provides models of feedback
Table 23.1 Models for Providing Feedback
One minute preceptor
Model BEAR [14]
Steps/
description
B—Explicit description
of behaviors
E—Explain the effect
of the behavior
A—teach receiver
alternative behavior
R—Discuss result of
new behavior and/or
consequences if not
remediated
[28] DESC [3] Pendleton [31] Feedback sandwich [22]
Get a commitment by
focusing on one
learning point about
the case
Probe for supporting
evidence
Reinforce what was
done well
Give advice/guidance
Teach a general
principle
Conclusion
D—Describe the
behavior
E—Express
feelings/thoughts
S—Make specic
recommendations
C—Communicate
consequences
Ask the
learner what
went well
Tell the learner
what went
well
Ask the
learner what
could be
improved
Tell the learner
what could be
improved
“Sandwich” critical feedback between
positive feedback
Positive feedback
Critical feedback
Positive feedback
*No longer recommended as rst line
feedback strategy in all cases as learners
often await the “but” in the sandwich,
neglecting to pay attention to full scope
of feedback