Belonging as a Core Trait Within the Practice of Medicine

Medicine has a long history of excluding certain groups from providing and receiving medical care based on race, ethnicity, gender, and disability status, to name a few.^1–3 Race-concordant care and gender-concordant care have been associated with improved patient outcomes, and many medical schools are working towards enrolling student bodies to improve the representation of currently under-represented groups in the future physician workforce, including Black, Latinx, LGBTQIA, low-income, and disabled people. Between 1978 and 2019, female-identifying medical students grew from 24 to 50%, yet enrollment of Black men remained stagnant from 3.1 to 2.9% and Hispanic/Latinx medical students under 6%.⁴ Familial wealth remains over-represented among medical students compared with the general population, and between 2017 and 2019, 24% of students came from families in the top 5% of US household incomes.⁵ This lack of diversity can lead to the under-identification of systemic issues that affect under-represented groups, and patients may not be accustomed to receiving care from physicians from under-represented groups. As a counter to these disparities in both providers and patient outcomes, we discuss the role of fostering belonging of all groups as a means to improve patient, learner, and provider commitment to continuous improvement, thereby ultimately optimizing patient care.

Belonging is the ability to exist authentically and wholly in an environment where individuals experience acceptance, security, and a sense of value as its hallmarks. Belonging is not siloed. It is the product of our interactions and connectedness as entities with other individuals within the institutions, organizations, systems, and the society in which we operate.⁶ Belonging is much more than inclusivity. It entails the full integration of individuals and communities historically excluded from medicine in a manner that empowers them to actively shape and contribute to the institutions in which they operate and to the healthcare system at large. Numerous forces inform and threaten one’s sense of belonging in an environment. By fostering belonging, each member of the medical continuum, from patients to providers, may be able to feel included and committed to the common cause of patient care and thus be able to challenge inequities in a psychologically safe setting.⁷ Several articles in this JGIM issue challenge readers to re-imagine practices for fostering inclusion and belonging in medicine. We highlight three articles that underscore the pivotal role that language and communication play as instruments in engendering an individual’s sense of belonging and cultivating the quality of belongingness within an institution. Ultimately, fostering belonging of traditionally under-represented groups in medicine will lead to a more diverse workforce and improved patient care.

A shared language to understand the lived experiences of unique groups acknowledges shared humanity and portrays an openness to walk alongside. Salinger et al. highlight the absence of a shared mental model for disability among program directors (PDs). While PDs acknowledge the grit of these individuals, they also share the uncertainty of workload distribution and needed accommodations. Importantly, this deficit framing of disability can perpetuate bias and catalyze the sense of “otherness” of residents with disability.⁸ As training programs and educators, we must move from reactive judgments about those with disabilities to a proactive shared understanding of what it means to have a disability; this includes having an umbrella definition of disability, characterizing the breadth of disability, and celebrating their lived experiences as a person and physician. The voices of students, residents, and physicians with disability must be centered and central in this discourse. Developing this shared perspective through curiosity and empathy is crucial to co-creating a culture of belonging and meaningful structural support in the medical profession for individuals with disabilities.

Next, we highlight an article that focuses on the patient’s belonging in the medical continuum. Precise, culturally responsive communication is essential to providing high-quality care to patients who are not English speakers. Language concordance between providers and patients enhances rapport, builds trust, and influences patients’ understanding of their health and engagement in care. The article by Valle Coto et al. shares the application of language self-assessment tools in medical students to determine readiness to provide language-concordant care and found that multilingual students had a higher proficiency threshold for delivering safe care than monolingual students.⁹ This tool transcends grammatical dexterity and requires contextualizing information within a cultural background. Nuances and subtlety of language that add color to the fullness and range may be lost. In our fast-paced and demanding medical environment, students and healthcare providers may utilize their limited language skills or rely on individuals without proper medical translation training to provide patient care. When physicians, including students, communicate with limited fluency in a language, it may signal to the patients that their doctors and, by extension, the hospital place limited value on delivering high-quality care to non-English speakers, further limiting belonging in an already vulnerable setting. It hampers and restricts the ability to provide patient-centered care. This jeopardizes the trust foundational to the patient-physician relationship, the same trust that fosters a sense of belonging for patients. We must encourage critical self-assessment of one’s own skills for true language fluency for the benefit of our patients and their own need to belong in our diverse healthcare system. Furthermore, institutions should commit both to recruiting trainees with diverse language proficiency and to training all trainees on appropriate use of certified interpreters.

Finally, we highlight an article on navigating learner discrimination by Beltran et al.¹⁰ Physicians, including medical learners from diverse backgrounds, often face discriminatory behaviors and attacks from healthcare professionals, patients, and patient families. These experiences impact their psychosocial wellness, professional well-being, and professional development, thus inhibiting a sense of belonging within the profession. These discriminatory behaviors range from microaggressions to overt discriminatory behaviors that threaten the provider’s immediate safety. Unfortunately, these events are not singular occurrences; these repeated messages signal that the individual does not belong here. Beyond the personal experiences of these biased attacks, the silence of other members of the team may reinforce feelings of invisibility for the diverse colleague as well as signal the acceptance of the poor behaviors, which leads to seclusion, isolation, and further alienation. Bystanders may be shocked by the observed event and feel ill-equipped to intervene and show allyship. Furthermore, the learner or provider who suffers from this victimization may feel the need to remove themselves from the care team, further impacting patient care. This article found that 43.9% of residents who participated in an OSCE intervention were initially not proficient in responding to and supporting a colleague who experienced discrimination.¹⁰ Although a single institutional study, these observations are likely commonplace in clinical learning environments across the country and highlight the urgent need to develop and enhance curricula for training individuals on addressing discriminatory behaviors. These educational programs should include instruction around the effective approaches highlighted in the OSCE, including naming the event and its unacceptability, demonstrating empathy through verbal and non-verbal communication, and engendering a sense of agency.¹⁰ They should be offered to everyone across the medical education continuum, from medical students to faculty. These trainings should equip individuals with the skills necessary to transition from bystanders to upstanders prepared to support and advocate for their diverse colleagues adequately and demonstrate allyship, promoting a culture of civility, respect, mutual accountability, and ultimately, belonging.

Going beyond the individual and interpersonal sphere, healthcare organizations and academic medical centers as entities must affirm belongingness as a core trait. This can be achieved by not just attesting to but proactively enforcing clear, comprehensive policies and procedures for addressing discriminatory experiences. These institutional policies should unequivocally demonstrate the value and importance of every individual (patients and professionals) regardless of race, ethnicity, religious background, disability status, and other markers of difference, thereby reinforcing our commitment to inclusivity and belonging. Fostering belonging in our learners, providers, and patients can facilitate their commitment to making a change in our history of systemic inequity. Belonging is a foundational prerequisite to optimal patient outcomes through the power of challenge and voice.