A Reflection and Discussion Exercise on Racial Justice and Equity

Abstract

Background

Residents have valuable perspectives about diversity and equity in medical training, yet many graduate medical education curricula lack dedicated activities focused on such issues.

Objectives

To describe and report feasibility and acceptability of an innovation that uses individual reflection and group discussion to create conversation in our residency program about equity and injustice through the lens of the Black Lives Matter movement.

Methods

In July 2020, we sent a survey with reflection prompts to all postgraduate year 2 and above internal medicine residents. In the discussion session (during required academic time), we presented 10 of the residents' responses to the reflection prompts. After each response was read aloud, the residents had an open discussion. We used thematic analysis to analyze the responses to the reflection prompts. Acceptability was tracked through free-text comments in the survey. Feasibility was measured by the time and resources needed to conduct the session.

Results

We received responses from 24 out of 72 (33%) residents. We identified 10 codes that fell into 4 themes. The most commonly identified codes included anger or frustration toward events, self-reflection on privilege, increased awareness and discussion of racism in daily life, and life being minimally impacted/homeostasis. The 4 overarching themes were (1) awareness, (2) motivation for change, (3) emotional response, and (4) self-reflection.

Conclusions

Using a format of reflection and sharing of anonymous responses was an inexpensive and effective method to begin a discussion about equity and injustice in medicine.

Objectives

The goal was to describe an innovation to create discussion in a residency program about equity and injustice through the lens of the Black Lives Matter movement.

Findings

The resident reflections fell into 4 themes, including awareness, motivation for change, emotional response, and self-reflection.

Limitations

The residents who responded may have been those who were most passionate about promoting equity and justice.

Bottom Line

An innovation using reflection and group discussion is feasible and possibly applicable to a variety of issues of importance to medical education.

Introduction

In May 2020, George Floyd, an unarmed Black man, was killed in Minneapolis by a White police officer after being handcuffed and pinned facedown with a knee on his neck for over 8 minutes, eventually causing cardiopulmonary arrest.¹ The gruesome nature of his death, and the major racial undertones that came with it, catalyzed demonstrations spearheaded by the Black Lives Matter (BLM) movement throughout America. In the medical community, the demonstrations helped organizations such as White Coats for Black Lives² gain traction, providing an opportunity to speak out against systemic racism both in and outside health care.^3-5 The events of 2020 should result in the medical education community, including residency programs, reflecting on what its role is in propagating systemic racism and what actions it could take to improve.⁶

Residents have a valuable perspective pertaining to the impact of diversity and equity within medical training and have been shown to be more comfortable than senior faculty discussing sociocultural topics.⁷ Yet many graduate medical education curricula lack dedicated activities to discuss topics of race or systemic bias in medicine, despite evidence showing that residents' knowledge of health disparities and cross-cultural care is poor,^8,9 and that racial minorities have poorer medical outcomes.¹⁰ The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements specify relevant core expectations of residents, such as demonstrating “respect and responsiveness to diverse patient populations” and being able to communicate effectively with a broad range of people.¹¹ In addition, the Milestones 2.0 for internal medicine programs also incorporates these principles through behavioral anchors that refer to understanding health inequities and social determinants of health.¹² Other specialties such as pediatrics and family medicine target similar competencies.^13,14 While the ACGME provides expectations for residents to attain competence in these areas, it is up to individual programs to implement methods to achieve them.

The innovation described here sought to offer a forum for reflection and discussion during the tumultuous summer of 2020 and to gauge how the death of George Floyd and the BLM movement affected residents' perspectives on racial inequality. We aimed to share this innovation and analysis of the residents' reflections so that other programs could implement similar interventions in the future.

Methods

Setting and Participants

This innovation occurred at a large urban tertiary care hospital. We included postgraduate year 2 (PGY-2) and above residents in the categorical internal medicine residency (n=53) and 2 combined programs (internal medicine/pediatrics, n=18, and internal medicine/anesthesia, n=1). In 2020-2021, the programs included in this innovation had 50% women and 10% underrepresented in medicine residents.

Description of Innovation

In July 2020, residency program leadership sent an anonymous Qualtrics survey to the PGY-2 and above residents (provided as supplementary data). We asked them to reflect on the BLM protests and George Floyd's death. Specifically, we asked them how their lives had been impacted by these events, how they were thinking about racial justice and inequity, and how their thinking had changed (if at all). The residents were given the option of allowing their anonymous responses to be shared during a required academic half day (AHD) session. We distributed the survey 1 week prior to the AHD session.

Two of the authors (K.F., S.D.) reviewed the responses before the AHD session and identified responses to highlight during the large group session. We chose 10 responses that represented a range of viewpoints and ideas. The session included 10 learners in person and approximately 30 virtually. The session was part of a required weekly AHD program. Each week during the pandemic, approximately half of the eligible residents attended, either virtually or in person, so this was a usual number of attendees. Since most residents were required to attend virtually, attendance was not tracked.

The program director and associate program director moderated the session. We used a PowerPoint presentation that included a slide on our program's values (diverse workforce, opportunities for everyone, and psychological safety) and a slide on how these equity and inclusion values can lead to fulfillment of program goals (diverse workforce contributes to excellent clinicians; opportunities for everyone contribute to happy, well residents; and psychological safety contributes to a supportive learning environment). The next slide contained the prompts for the written responses, followed by 10 slides that each had one anonymous response from a resident. We read one response and then asked the participants to react to it, with discussion occurring after each response slide. The session lasted for 45 minutes (see Table 1 for a timeline, tasks, and hints for implementation).

Table 1.

Timeline and Tips for Using Reflection/Discussion to Explore Resident Perceptions of Racial Inequity in Medicine

Timing	Task With Black Lives Matter Example	Notes/Advice
1-2 weeks prior to planned session	Reflection prompts developed	If planning this session in response to a time-sensitive event, these prompts may be developed more quickly.
1 week prior to planned session	Prompts emailed to residents via anonymous survey • Reflect on the last few weeks beginning with George Floyd's death and the Black Lives Matter protests, then answer the following questions. • How has your life been impacted by these events? • How are you thinking about racial justice and inequity? How (if at all) has your thinking been changed by these events? • Please feel free to provide any additional thoughts/comments in this space. You are welcome to provide your name, but you do not have to.	Use open-ended prompts. Give residents the option of having their anonymous responses shared during the planned session.
1 day prior to session	Facilitators reviewed responses and identified those that would be shared in the session	Aim for a range of ideas. Aim for a range of opinions. When several people espouse a similar view, choose one to represent that view.
1 day prior to the session	Facilitators developed a PowerPoint presentation for the session • Background information about diversity/equity/inclusion goals of the program • 10 slides with 1 response on each slide	Be realistic about how many slides you can get through and still have a robust conversation about each. For our session, which was only 45 minutes, 10 slides were probably too many.
The day of the session	After each response was read out loud, the residents had an open discussion, which required very little facilitation.	Be prepared for some silence, especially at the beginning.

Analysis of Data

We analyzed the residents' responses to the prompts using thematic analysis.¹⁵ Two authors (R.P., N.A.) read the responses, developed a coding scheme, and independently coded all the responses. They then compared their responses, came to consensus, and adjusted the coding scheme, resulting in 10 codes (Table 2). The author group discussed the codes, finalized definitions for them, and organized them into 5 overarching themes. Finally, a third author (K.F.) independently coded all the responses using the final coding scheme. We compared K.F.'s coding to the consensus coding of R.P. and N.A., then discussed all disagreements until reaching consensus.

Table 2.

Themes, Codes, and Representative Quotes From the Analysis of Resident Reflections

Code	Code Description	Representative Quote
Theme 1: Awareness
Increased awareness and discussion of racism in daily life	Response indicated that the events have brought more attention to the topic of racism and racial disparities in their day-to-day life, perhaps thinking about it more often than they normally do.	“There has been more unrest in our community and more discussions about this movement. Some made me uncomfortable; some made me feel better.” “It has brought up conversations about race that wouldn't have been generally brought up in the past.”
Problem is nothing new, but light has been shone on it	Response acknowledged that the events highlight the problem of racism but does not express surprise toward them.	“It should have been addressed much sooner. The intrinsic bias against different races other than White would be difficult to eliminate.” “It exists. And should be addressed.”
Newfound/improved realization of racism	Response indicated a new understanding (not just increased) of racism or new motivation to help spread change.	“Realizing that being anti-racist is very active. It is more than just saying, ‘I am not a racist.'” “I have been able to think more in-depth about these issues as there are more discussions about it.”
Theme 2: Emotional Response
Overwhelmed by events—including scope of protests, fear for personal safety, lack of knowledge in how to get involved	Response indicated feelings of helplessness provoked by the events in relation to the scope of racism or how to help the issue.	“Emotionally unpacking has been difficult and knowing what to do to contribute meaningfully to a better society is overwhelming.” “It's frustrating to see how it takes all these protests to guide institutional change. I don't know how treating everyone as equals is even a debate.”
Anger/frustration toward events	Response indicated emotional response of anger, frustration, or disappointment toward the death of George Floyd and the current state of racial disparity in their life or society.	“I am confused on how our residency program feels about systemic racism/racial injustice. I see these emails from Dr. Simons, and yet I see no response from our program director. I am angry because we should be welcoming to our new interns of color rather than making them worry that they may not feel supported by our program.” “Yes, I am appalled at what happened and with the lack of respect for human life by that individual police officer. Really highlighted the racist undertones of our country.”
Theme 3: Self-Reflection
Self-reflection on privilege	Response reflects on the privileges one's race affords (or does not afford) them, and how that might affect their life experience.	“There have been protests in my area. Has made me examine my own life and the amount of privilege I have.” “I am trying to be conscious of racial bias in my practice and trying to read books/watch documentaries in my free time relating to racial injustice.”
Self-reflection on personal actions and identity	Response reflects on how one's personal actions may help propagate or dismantle racism within their personal and professional lives.	“This has allowed me to really self-reflect on my own bias and be more conscious about checking these at the door before I walk into a patient's room.” “Reevaluating the health disparities and context in which our patients present to clinic and to the hospital.”
Theme 4: Motivation for Change
Homeostasis—life was minimally impacted	Response indicated that the events did not affect their life or worldview significantly.	“To be honest, my life has been very minimally impacted other than getting more emails and hearing more about social injustice.” “Sadly, it hasn't been directly affected. The weirdest thing was being overnight in the hospital and getting the stay-at-home alerts on my phone.”
Hope for the future	Response indicated hope that the events will inspire positive change in the country.	“I think it was nice to see how many people turned out in protest to stand up for Black lives.” “The persistence of racism in our society does make me concerned for my family and my safety and well-being, especially with our current government. But I am hopeful that these protests are a sign that the majority of Americans are fed up with our current status quo and will continue to fight for change.”
Consciously increasing respect for others	Response deliberately indicated intent to improve how they view and treat patients and co-workers, especially in the context of race.	“I've gained a ton of respect for those I interact with and their morality.” “Lot more people being more respectful of others who are not like them.” “Structural racism exists within the systems in which we work, including within medicine. I personally believe it is our responsibility to be not only ‘not racist,' but to be ‘anti-racist.' If we don't speak up and out about injustices, change cannot occur, and what we tolerate, we promote.”

We received approval from the Medical College of Wisconsin Institutional Review Board to analyze the anonymous responses.

Results

The primary outcomes were themes from the free-text responses. Twenty-four out of 72 residents answered the prompts (33%). There were 54 codable responses to the prompts.

We identified 10 codes that fell into 4 themes (Table 2). The most commonly identified codes included the following: (1) Anger or frustration toward events (“This is what is so disappointing when terrible moments and powerful movements to initiate change occur. The momentum seems to fizzle out and life goes back to normal.”); (2) Self-reflection on privilege (“As a white individual, these events have inspired me to work on the ways that I am ‘racist' in my own life. I also think about how ‘systemic racism' affects the care that my patients of color receive and how systemic racism impacts our residency program and the residents of color we have and are planning to recruit.”); (3) Increased awareness and discussion of racism in daily life (“It has brought up conversations about race that wouldn't have been generally brought up in the past.”); and (4) Life was minimally impacted/homeostasis (“To be honest, my life has been very minimally impacted other than getting more emails and hearing more about social injustice.”).

The full code list was organized into themes that more broadly highlight the pattern of residents' reactions. The 4 themes were (1) awareness, (2) motivation for change, (3) emotional response, and (4) self-reflection. The theme of awareness contains codes that displayed an increased level of attention toward racism after the death of George Floyd, whether that was a brand-new realization of its effects or a reminder of its existence. The theme of motivation for change contains a spectrum of codes that display willingness to take action to fight racism in one's personal life or on a greater level. This spectrum ranged from no motivation for change (homeostasis), to hoping society will change and willingness to support this change (hope for the future), to willingness to take deliberate actions to change one's own behavior (consciously increasing respect). The theme of emotional response contains codes that mainly convey emotion in their message such as anger, disappointment, or feelings of being overwhelmed. The theme of self-reflection contains codes that demonstrate self-examination of one's relationship with racial identity and privilege.

Inspection of the free-text comments showed evidence of acceptability (eg, one respondent called it “much needed”) and no evidence of unacceptability. From a feasibility standpoint, the resources needed for this session included time for our program coordinator to import the survey into Qualtrics (30 minutes) plus time for our program director and an associate program director to write the survey questions, plan the session, and moderate the session (approximately 10 hours total). We used time designated at a protected AHD to conduct the session (45 minutes).

Discussion

In July 2020, we collected individual resident reflections about the BLM protests and used some of the reflections to spark discussion during protected curricular time. The residents expressed a range of feelings and insights about the events as they were occurring. This was exemplified by themes such as awareness and motivation for change, each of which contained codes representing different levels of recognition and motivation to dismantle systemic and personal racism. Codes such as homeostasis represented indifference toward the BLM movement while newfound realization of racism, hope for the future, and consciously increasing respect represented a more optimistic mindset driven toward making change.

Interestingly, homeostasis was the most applied code and contained responses that were shorter and less engaged. This may be indicative of a lack of “buy in,” as Betancourt and Green describe, in which clinicians must believe in the concept of cultural competency before being able to change their perspectives.¹⁶ Finding ways to increase the priority of anti-racism in the minds of those who are indifferent will be key to improving the productivity of sessions like these and combating inequities in general.

Although residents were not required to share their thoughts during the group discussion, many did. This optional in-person sharing is similar to the principles of group therapy.¹⁷ Although group therapy was not an explicit purpose of the session (and the session was not led by a licensed mental health professional), it did generate discussion among the group on common feelings, individual experiences, the ability to discuss challenges encountered, and how to be supportive as a whole. It also led to discussions of how to move forward as a program and how to be advocates for change, including ideas about recruiting more diverse resident classes, normalizing discussion around implicit bias in medicine, and engaging with groups of varying backgrounds.

A recent study by Chary et al of a resident-led health equity retreat found similar positive outcomes in promoting awareness and solutions for addressing racism as health care professionals.¹⁸ Sessions like ours offer a simple way for residents to widen their perspectives and advance the goals of dismantling racial inequity and systemic racism in medicine.¹⁹ Future efforts could involve specialties outside of internal medicine and could incorporate exploring solutions for the racial inequity that residents witness or experience in their lives, as these issues are not specific to internal medicine. Another direction for this type of innovation is to hold sessions periodically in response to current events. For example, creating time for discussion and reflection during the COVID-19 pandemic has been shown to be an effective tool for addressing collective trauma and burnout in residents.²⁰

One limitation was not collecting structured resident feedback on the session. Additionally, the effort required to answer open-ended questions may have biased our responses toward people who held stronger views. People who did not respond may have represented those who were less committed to racial equity and justice. Social desirability bias also could have played a role in how residents answered the questions.

Conclusions

In summary, we learned that using a format of written reflection followed by sharing of selected anonymous responses was an effective method to discuss sensitive topics in a larger group. We also defined 4 key themes about racial equity that other programs may hear from their residents, should they implement a similar session.

Funding Statement

Funding: The authors report no external funding source for this study.