Teaching in the Anti-Racist Growth Zone: Lessons from a Clerkship Session on Racism and Microaggressions in the Clinical Setting

by Damian K. L. Archer, MD, Tufts University School of Medicine, Department of Family Medicine, Boston, MA; Sarah Rosenberg-Scott, MD, MPH, Tufts University School of Medicine, Department of Family Medicine, Boston, MA; Amy L. Lee, MD, Tufts University School of Medicine, Department of Family Medicine, Boston, MA

Background

It can be challenging to effectively teach medical students how to recognize and safely address racism, bias and microaggressions in the clinical setting,¹ especially when most faculty report lack of training, resources, and expertise in this area.² A recently published CERA study demonstrated that 60% of US Family Medicine (FM) clerkships had no formal curriculum addressing racism or bias.³ Faculty must courageously lean into an anti-racist growth zone⁴ to move toward health equity and justice in clinical learning environments. In 2019, the Tufts University School of Medicine FM clerkship launched an interactive educational session on racism and microaggressions in the clinical setting. Here, we share lessons learned about developing and improving that session over the past four years.

Methods

Three faculty members who have participated substantially in diversity, health equity and inclusion work and hold diverse identities, collaborated to develop and teach the clerkship session. Students and faculty, in small groups, discuss a clinical scenario of a 9-year-old child with behavioral problems reported by his school (see Table 1). The child’s mother reports difficulty interacting with the school and is concerned that her child isn’t being treated fairly. We explicitly state why the patient’s race, ethnicity, and heritage as depicted in an accompanying family genogram were included in this case – because we will be discussing how racism and bias could be involved.

Table 1: Discussion Case and Prompts

Case Presentation Part 1:

Nine-year-old Ramon Santiago presents to your office with his mother, Julia, who is upset because she received a letter from Ramon’s principal stating that he was in jeopardy of being suspended from school due to repeated complaints from multiple teachers about disruptive behavior. She states to you in the visit, “Ramon is a good boy at home but when he goes to school the teachers complain that he disrupts the class, and it has affected the other children in his classes.”

Julia reports that she spoke with the school guidance counselor when she first received a teacher complaint and had to ask multiple times for assistance before the guidance counselor set up an evaluation with the school psychologist. Julia didn’t feel the psychologist listened to her concerns when she stated that she believed the teachers weren’t treating Ramon fairly.

Ramon’s vital signs today are T98.7, Wt 80 lbs Ht 55 in, BP 101/70 HR 90 RR 20

A focused physical and developmental exam is within normal limits for age and sex assigned at birth.

** This medical scenario specifically aims to assess the impact of racism and bias on the health of this LatinX family as disclosed in the genogram. **

Discussion Prompts Part 1:

What other questions do you have?
What do you think is the cause of Julia’s concern (what’s on our differential diagnosis)?
How will you discuss your concerns with Ramon and Julia?
How do we support and advocate for Ramon’s wellbeing?

Case Presentation Part 2:

You present your assessment and plan to your preceptor. When you discuss the concern for racism and bias, your preceptor dismisses the racism and bias assessment and says, “These people always think it’s racism, let’s try to stick with medical science, ok!”

Discussion Prompt Part 2:

How could you respond to the microaggression the preceptor committed?

Students were asked to consider how racism and bias could be affecting the patient, and then were guided through a learning scenario where the attending clinician in the case commits a microaggression against the patient and his family. The learning objectives of the session were to: describe the impact of racism, bias, and microaggressions on the health of patients and their families, create a plan to advocate for and support patients impacted by racism, bias and discrimination, and identify and respond to microaggressions. Anonymous Likert scale ratings and narrative feedback of the session were collected, in addition to personal “take home” points students wrote and could optionally share at the end of the session.

Results

During the academic year 2021-2022, the session received an average student rating of 3.58 out of 4 on a Likert scale for usefulness of topic and effectiveness of teaching, consistent with the average ratings of other didactic sessions in the FM clerkship. Narrative feedback and shared student “take home” points have been informative and encouraging (see Table 2). Students appreciated the importance of a session on this topic in the clerkship, the approach used by the teaching faculty, and the usefulness of the frameworks and skills shared to identify and respond to racism, bias, and microaggressions in the clinical setting.

Table 2: Student Narrative Feedback and “Take Home” Learnings

Representative anonymous student narrative feedback:

The bias reduction discussion was really good. I think the framework gave people time to reflect on a topic and apply it to something they've seen in medical practice when you opened it into discussion groups.
I really enjoyed my microaggressions/racism small group because I thought it gave me action items and an algorithm to handle visits like the case we went through.
The framing of microaggressions with tangible intervention ideas if we're comfortable was useful.

Representative “take home” learnings shared by students:

“Moving at the speed of trust” is crucial with patients and families.
Doctors can advocate for families within the school system.
Racism and discrimination should sometimes be on the differential diagnosis.
The way a person decides to respond to a microaggression is not the problem, the microaggression itself is the problem.
There’s a difference between safety and comfort when it comes to responding to racism, bias, and microaggressions and there are opportunities to stretch into the “Growth Zone” to learn to address these issues more effectively.

Conclusion:

These are some of our most important lessons learned:

Having a group of trained and supported faculty with diverse identities and life experiences is very helpful when developing and implementing anti-racist teaching approaches that confront oppression within the healthcare and medical education systems.
Explicit framing of how and why race is being used in a clinical teaching case is important to prevent perpetuating racist stereotypes.
Starting with group discussion agreements helps to prevent harm and keeps students open to engaging in challenging conversations.
Students desire and value the opportunity to learn anti-racist principles and clinical approaches.
Continuous improvement of the content and delivery in response to student and faculty feedback is important to ensure a high-quality learning experience for all.

As more anti-racist and inclusive learning experiences enter our medical school curriculum, we anticipate this session will evolve to meet the needs of students learning to apply anti-racist skills in the clinical environment and beyond. We have experienced the benefits and growing pains of leaning into the anti-racist growth zone as clinical teachers and believe this is a necessary component of developing effective anti-racist medical education.

References:

Sue DW, Lin AI, Torino GC, Capodilupo CM, Rivera DP. Racial microaggressions and difficult dialogues on race in the classroom. Cultur Divers Ethnic Minor Psychol. 2009 Apr;15(2):183-90. doi: 10.1037/a0014191. PMID: 19364205.
Fatahi G, Racic M, Roche-Miranda MI, et al. The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers. Ann Fam Med. Feb 2023, 21 (Suppl 2) S14-S21; DOI:10.1370/afm.2919 https://www.annfammed.org/content/21/Suppl_2/S1
Bridges KM, Rampon K, Mabachi N, et al. More Than Half of Family Medicine Clerkships Do Not Address Systemic Racism: A CERA Study. Fam Med. 2023;55(4):217-224. https://doi.org/10.22454/FamMed.2023.581155
Ibrahim AM. Becoming Anti-Racist Diagram, inspired by the work of Dr. Ibram X. Kendi. https://www.surgeryredesign.com

Additional Resources:

Jackson A, O’Brien M, Fields R. Anti-Racism and Race Literacy: A Primer and Toolkit for Medical Educators. UCSF. https://diversity.universityofcalifornia.edu/files/anti-racism-and-race-literacy---a-primer-and-toolkit-for-medical-educators_june-2020.pdf
Sue DW. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken New Jersey: John Wiley & Sons; 2010.
White-Davis T, Edgoose J, Brown Speights JS, et al. Addressing Racism in Medical Education: An Interactive Training Module. Fam Med. 2018;50(5):364-368. https://journals.stfm.org/familymedicine/2018/may/white-davis-2017-0183