Optimizing the Learning Environment to Improve the Experience of Underrepresented Trainees

Increasing institutional capacity for diversity in medicine has gained considerable attention in recent years. This has led to new opportunities for learning and overcoming challenges not only in the care of patients but in the education of our learners. In an article titled “Why Black doctors like me are leaving faculty positions in academic medical centers,” Dr. Uche Blackstock, an African American physician formerly on the faculty at New York University and now a best-selling author, identifies lack of mentorship and toxic work environments characterized by micro/macroaggressions as reasons why she left academic medicine (asamonitor.pub/3TN3sPl). She is not alone. Results of a survey (N=1,994) of full-time faculty (53% women and 24% underrepresented minorities in medicine, or UIM) from 26 representative U.S. medical schools revealed that 21% had considered leaving academic medicine because of dissatisfaction with a culture characterized by isolation and feeling invisible (Acad Med 2012;87:859-69). This culture or climate has been associated with burnout, which for affected anesthesiologists may also be a reason they leave (Anesthesiology 2024;140:38-51; Am J Lifestyle Med 2020;15:118-25; Biomed Res Int 2017;2017:8648925). While faculty members have some latitude in considering other opportunities, UIM trainees needing to complete medical school and training for certification must navigate a potentially injurious learning environment (Acad Med 2013;88:1765-77). In a 2017 Association of American Medical Colleges (AAMC) graduation questionnaire, 7% of responding medical students indicated that they had been subject to racially or ethnically offensive remarks by faculty, staff, or other learners (asamonitor.pub/49mOqFW).

“Learning climate” refers to the social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape learner experiences, perceptions, and learning (asamonitor.pub/49rDRRN). To help foster a more beneficial learning experience and aid in the development of strong social connections between learners and educators, a learning climate should promote a sense of belonging through cultural sensitivity. A deficient learning environment, characterized by poor social interactions, emotional support, cultural connection, and career encouragement, may manifest in biased evaluations and a lack of structured mentorship (Acad Med 2013;88:1765-77; Teach Learn Med 2020;32:110-6). Studies show that UIM learners experience less supportive and less positive learning environments, are subject to discrimination and harassment, and are more likely to see race as having a negative impact on their medical school experiences compared to non-UIM students (BMJ 2020;368:m339). The impact on these learners is consequential. A lack of psychological safety and trust leaves UIM learners in constant fear of being rejected (Acad Med 2013;88:1765-77). In hostile social environments, learners can question their ability, skills, and accomplishments, which leads to self-doubt and self-consciousness about their identity and legitimacy (imposter syndrome) (Teach Learn Med 2020;32:110-6; Acad Med 2007;82:146-53). This suboptimal learning climate leads to isolation, burnout, suppressed academic success, limited career advancement, and a higher rate of attrition (Acad Med 2013;88:1765-7). Despite fostering diversity, equity, and inclusion (DEI) in both the health care workforce and medical education, “differential attainment” – defined as a gap in the levels of achievement in academic performance and career progression in medicine – is still common in UIM groups when compared to non-UIM groups (Teach Learn Med 2020;32:110-6). Promoting a sense of belonging, particularly for UIM learners, may help remedy this gap (Acad Med 2007;82:146-53).

While institutional-level support in the form of visiting student programs helps ensure that UIM students have access to medical training programs, a positive learning environment appears to play a role in their success (asamonitor.pub/49vZW1R). The groundwork for promoting a sense of belonging in a profession that has historically excluded UIMs requires an infrastructure that offloads the responsibility of navigating systems of racism from learners and creates a space for educational interventions that foster understanding, self-reflection, and discussion (Teach Learn Med 2020;32:110-6). In 2022, the Medical College of Wisconsin pediatrics residency program created an anonymous survey for reporting microaggressions that allowed for tracking of incidents and intervention (Figure). Noting low engagement in its first year, they revised the response algorithm to focus on victim support, in addition to educational interventions. Following these changes, the rate of reporting doubled. Recipients of microaggressions were primarily residents, and the aggressors were mostly faculty/staff. All identified residents received peer support. Coaching and education are available and are planned in response to all reports. A summary of the reports and interventions are shared semi-annually with residents. While some residents have reported concern over retaliation, they feel heard and appreciate the transparency in the response process. Plans include mandated microaggression training for our faculty and bystander simulations for our residents. The outcome is that victims feel validated and that there is a system to intervene with those perpetrating microaggressions.

Creating a safe space for understanding, self-reflection, and discussion between faculty, learners, and staff will require broad educational interventions that include outcomes and impact. Eliciting the social sciences to incorporate social justice, health equity, and cultural humility in trainee education and faculty development programming enlists both faculty and students to explore topics like advocacy, and the role of social determinants in disease, cultural wealth, and professional identity development (Teach Learn Med 2020;32:110-6; Race Ethnicity and Education 2005;8:69-91). Programming to promote cultural humility for relationship-building through small-group discussions on self-identity, privilege, and microaggressions has been well-received and is an important starting point for DEI work in medicine (Teach Learn Med 2020;32:110-6; Acad Med 2020;95:s51-7). Survey results from the University of Chicago’s Identity and Inclusion (i2i) Committee, which was established to foster school-wide engagement of students, faculty, and administrative staff around issues of identity and inclusion, have been positive. The first four years of this program revealed a significant improvement in students’ sense of inclusion: 83% and 77% of medical students agreed that they felt a sense of belonging/community at the University of Chicago Pritzker School of Medicine in 2016 and 2018, respectively. Broadening DEI initiatives to be all-encompassing in program aspects and for all participants is an important step in helping to create a community that supports all learners.