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.

Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments.

PURPOSE: Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. METHOD: A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. RESULTS: Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. CONCLUSIONS: This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

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

PURPOSE: This study explores medical students' perspectives on the key features of ideal supervisor responses to microaggressions targeting clerkship medical students. METHOD: This single-institution, qualitative focus group study, based in an interpretivist paradigm, explored clerkship medical students' perceptions in the United States, 2020. During semistructured focus groups, participants discussed 4 microaggression scenarios. The authors employed the framework method of thematic analysis to identify considerations and characteristics of ideal supervisor responses and explored differences in ideal response across microaggression types. RESULTS: Thirty-nine students participated in 7 focus groups, lasting 80 to 92 minutes per group. Overall, students felt that supervisors' responsibility began before a microaggression occurred, through anticipatory discussions ("pre-brief") with all students to identify preferences. Students felt that effective bystander responses should acknowledge student preferences, patient context, interpersonal dynamics in the room, and the microaggression itself. Microassaults necessitated an immediate response. After a microaggression, students preferred a brief one-on-one check-in with the supervisor to discuss the most supportive next steps including whether further group discussion would be helpful. CONCLUSIONS: Students described that an ideal supervisor bystander response incorporates both student preferences and the microaggression context, which are best revealed through advanced discussion. The authors created the Bystander Microaggression Intervention Guide as a visual representation of the preferred bystander microaggression response based on students' discussions. Effective interventions promote educational safety and shift power dynamics to empower the student target.

How Medical Educators Can Foster Equity and Inclusion in Their Teaching: A Faculty Development Workshop Series.

PROBLEM: Diversity, equity, and inclusion are increasingly highlighted in medical education, but bias continues to disproportionately impact learners from racial and ethnic groups traditionally underrepresented in medicine. Many faculty struggle to engage with these concepts in their teaching and fear making mistakes, but few opportunities exist for faculty to develop their skills. APPROACH: To advance the goal of fostering an equitable educational environment, the authors envisioned a series of faculty development workshops to cultivate faculty skills and comfort with incorporating equity and inclusion in their teaching, assessment, and curriculum development work. The authors conducted a needs assessment and followed Kern's 6-step process for curriculum development to build the workshop series. OUTCOMES: Using local resources and expertise, the authors built a workshop series that culminated in a certificate in Teaching for Equity and Inclusion. The development process took 24 months; 22 faculty volunteered to design and teach 7 new workshops. Initial workshop offerings have reached 101 participants, and 120 faculty members have enrolled in the certificate. The workshops have been well received and are rated on par with or more highly than other faculty development offerings at the University of California, San Francisco. NEXT STEPS: Future directions include assessing the impact of the certificate on participants and workshop faculty, creating opportunities for workshop faculty to share best practices, and exploring alternative models for participation. The authors' experience demonstrates the feasibility of creating a self-sustaining program that will advance faculty competence in the critical areas of diversity, equity, and inclusion.