Perspectives on Inclusivity and Belonging in Canadian Graduate Medical Education: Insights from Palliative Medicine Residency

Abstract

Objective:

We present the perspectives of learners, preceptors, and institutional leaders regarding equity, diversity, inclusion (EDI) in the context of graduate medical education, with a specific focus on palliative residency.

Dialogical Process and Findings:

In this perspective piece, we share five key learnings established through a series of dialogical sessions, in which we highlight that while all individuals in medicine want to support the growth and safety of underrepresented learners, pervasive barriers prevent change. For learners, fear of repercussions and lack of safe feedback mechanisms prevent many from sharing perspectives around EDI. Underrepresented learners feel particularly powerless when witnessing care provided by preceptors to diverse populations in a manner that goes against their knowledge of cultural safety. For preceptors and institutional leaders, lack of training in cross-cultural education, fear of conflict and crossing boundaries, alongside challenges navigating how to support others using an EDI lens, prevents many from acting. Notably, all groups express self-doubt when experiencing microaggressions, but power dynamics particularly amplify this among underrepresented learners. A desire to maintain a guise of peace and harmony also perpetuates silence and inaction when opportunities to work through conflict arise.

Conclusion:

Our findings indicate that the current models of EDI in medical education take a reductionist approach centering on reprimand and blame of individual actors, resulting in increasing silence and siloing. We posit that a more humane and unifying approach that emphasizes the complexity and value of holding space for diverse views using dialogical skill provides essential grounding to better operationalize inclusivity and belonging in medical education.

Background

North American medical education frequently overlooks traditions and practices from diverse cultures, leaving health care professionals unprepared to meet the needs of patients from varying backgrounds.^1–5 Instead of critical analysis of medical education’s norms, these conventions have become entrenched as the standard of care, while culturally grounded practices risk being misinterpreted as noncompliant, compromising quality of care, or in complete combat with evidence-based practices. ⁶ Notably, medical learners from underrepresented backgrounds bring with them specific social, cultural, and historical experiences that profoundly shape their interactions with preceptors and patients. When medical education fails to integrate diverse cultural perspectives, learners from underrepresented backgrounds may feel their cultural identities being undervalued, leading to disengagement and alienation within their training environments.^7–12

Physicians, regardless of their religious, ethnic, or cultural identity, trained exclusively through the current prevailing lens may not have the skills to provide holistic and patient-centered care for the diverse populations they serve.^2,3 This is particularly important in countries like Canada, where first- and second-generation immigrants, together, make up approximately 40.6% of the population. ¹³ The field of palliative care is a pivotal example where skillfully assessing and then addressing the varying physical, spiritual, and psychosocial needs of seriously ill patients from diverse background is essential. ¹⁴ In palliative medicine education, the impact of underrepresenting the perspectives and preferences of nondominant cultural, racialized, and religious groups ³ leads to clinicians being ill-equipped to support diverse populations at the end-of-life, exacerbating issues around timely access to and the delivery of high-quality palliative care.^15–17

To better account for the varying perspectives and needs of a diverse patient population, as well as recognizing the structural inequities that impact underrepresented and vulnerable populations, equity, diversity, and inclusion (EDI) strategies have become central to discussions across Canadian medical schools ¹⁸ and even serve as a foundation for admission policies in new medical programs. ¹⁹ While tremendous work has been done to develop EDI strategies across medical schools, limited data explores the perceptions of learners, preceptors, and institutional leaders on their experiences with current EDI strategies in medical education. There is significant and legitimate concern that current EDI approaches oversimplify group identity and potentially perpetuate stereotypes and divisiveness while diminishing a sense of belonging, critical dialogue, and learning essential for transformative change. This article seeks to fill a clear gap in EDI and medical education, particularly in the context of critical dialogue as a key starting point for educating diverse learners in palliative residency while promoting authentic listening, generosity, and humble curiosity as prerequisite teaching skill for medical educators. While this focus narrows the context, we believe that the lessons shared in this perspective piece are highly relevant and timely for all medical educators who prioritize fostering learners’ sense of belonging as foundational to growth and unity within the medical and educational systems.

Reflective and Dialogical Process

To produce insights and actionable recommendations that can support inclusive practices within medical education using a quality improvement lens, a series of dialogical sessions were conducted with learners, preceptors, and institutional leaders across an Ontario-based palliative residency network. Specifically, two group dialogical sessions were conducted, followed by three one-on-one sessions. The methodology selected by the senior author (R.M.) was intended to emphasize the prerequisites of critical dialogue that challenges norms: the invited group was small (12 or less); involved diverse facilitators (both learners and educators); centered on authentic demonstration of a bidirectional relationship of respect between educator (R.M.) and learners (M.F. and S.B.) through active listening, humility, attentiveness, and curiosity during conversations; and used shared storytelling to prompt conversation about the intersection of identity, values, and lived experiences.

Alongside storytelling, questions to simulate praxis were used as methods to stimulate individual and group reflection and advance the exploration of very personal, often contentious issues around medical education (e.g., end-of-life care, death and dying, suffering and vulnerability, and the perception of injustice in medical education). During the dialogical sessions, the lead facilitators (R.M., M.F., and S.B.) emphasized that the space created was safe and one in which individuals could share their experiences, thoughts, and concerns without fear of judgment. Two members of the team (S.B. and M.O.) took detailed field notes during the sessions with verbal consent from all participants. Sessions were not audio or video recorded to reinforce the safety of all participants.

The first group gathering invited 12 members from across the network who identified as key leaders in clinical education and/or had an academic focus on EDI in palliative care. A second session was held with all faculty who were in the first three years of their clinical practice in palliative care post residency, as those who recently transitioned from resident to faculty were considered to have a unique lens on these issues. At minimum, two residents participated in both sessions. Finally, three one-on-one meetings were held with preceptors who articulated a need for leadership to provide more guidance on EDI-related education issues. Following each session, the project team debriefed and interpreted salient ideas. Once the team felt ideas were saturated, a group meeting was held to conduct a joint preliminary line-by-line review of all field notes. Each member further annotated field notes individually. Team discussions were held to distill annotations to a list of five key learnings.

Key Learnings

Care for patients should not eclipse compassion for learners

One of the first challenges that participants raised was that palliative care as a specialty is often viewed as one with “nice people who role model compassion.” Although this has elements of truth, participants noted that this reputation can be dangerous, as it may obscure the reality that those within the field can also perpetuate systemic biases in both preceptor-patient interactions and preceptor-learner interactions. Concurrent to this, participants expressed that the focus of palliative care on supporting seriously ill or dying patients can create an environment where the suffering of patients eclipses the well-being and needs of learners. In other words, preceptors adopt an EDI perspective that focuses particularly on caring for vulnerable patients. While this is integral to the profession, there is a risk that this deep empathy for the dying or vulnerable patient can hinder preceptors from recognizing the need to express compassion toward learners. Contributing to this dynamic and tension, participants noted that palliative care settings are emotionally and clinically complex, and as such, the expectations are heavy for palliative care physician-educators, particularly in high-stake contexts like busy acute palliative care units or in complex end-of-life conversations in home settings. Yet learning requires deliberate pause, intentional reflection, and safe preceptor-learner relationships. In reference to the literature, ²⁰ participants noted that pausing and reflection improves problem solving, professionalism, and clinical practice in medical education. Participants noted that preceptors who were energized and reflective in their clinical work were more likely to be able to simultaneously address the considerable needs of their patients alongside the unique needs of their learners in comparison to preceptors who seemed emotionally drained.

Additionally, participants highlighted that securing an academic appointment or becoming a clinical educator often did not require a demonstrated commitment to mentoring learners or building meaningful and supportive relationships with trainees. The focus tended to skew toward academic achievements, such as publications and research, and one’s excellence in clinical practice, rather than the interpersonal skills necessary to cultivate allyship and mentor-mentee relations. However, participants noted that being a skilled clinician or researcher does not automatically translate into being an effective educator. Participants also noted that while medical schools address microaggressions and mistreatment toward patients, and hospitals sometimes do the same toward staff, there is no mandate for faculty to participate in professional development sessions on these important issues toward learners. Additionally, while staff physicians receive extensive training in professionalism and patient care, participants mentioned a noticeable gap in learning to be effective educators. Many recognized that this persistent trend of deprioritizing learners can have negative implications and discussed the desire to improve their educational training to better support learners thriving in emotionally demanding environments such as palliative care.

Conversely, learners passionately expressed that when preceptors engaged them in meaningful mentorship, their confidence and sense of purpose in medicine were strongly improved. These preceptors often became trusted people they could debrief with when they experienced difficult situations, particularly incidents that had undertones of bias that made learners feel excluded with a diminished sense of belonging in medicine. This was particularly important in addressing feelings of isolation among palliative care residents. Learners also expressed that not having the burden of educating their preceptors on how to support them was associated with a greater sense of trust. Building on this thought, participants stressed that to better approach EDI for medical learners, a need exists for: hiring educators based on their demonstrated capacity to build mentor-mentee relationships and/or their commitment to learners; increasing recognition of the importance of interpersonal skills for serving as an educator; and integrating mandatory training in essential communication skills grounded in more nuanced, dialogical-based, and inquiry-based cultural safety for all educators that encourages the pursuit of shared knowledge and unity rather than divisiveness.

Safe spaces and bidirectional feedback are needed in medical education

Preceptors noted that they often struggled to provide high-quality feedback to learners who came from increasingly diverse geographic, religious, ethnic, racial, or sociodemographic backgrounds. Participants expressed that this is due to several reasons, including lack of training on how to deliver feedback in emotionally charged environments, alongside significant discomfort on how to respectfully communicate with people who already feel like outsiders in the system even when meaningful constructive feedback might augment their learning and growth. All participants expressed the importance of receiving such feedback to augment their opportunities to develop, yet it appeared that disproportionally these learning opportunities diminish when there is a lack of congruence in perceived learner and educator identity. To reconcile this clear gap in learning and relational opportunities for diverse learners, educators expressed wanting more experience around engaging in “learning conversations” such as conversational, collaborative dialogues (similar to what was demonstrated in the design of small group dialogues in our study) that fosters bi-directional learning, reflection, and professional growth,^21,22 instead of giving feedback through the conventional, hierarchical, one-directional approach from preceptors to trainees that diminishes the potential for a shared understanding through humble curiosity and active listening.

Participants also noted that in the context of medical education, there is often an absence of safe and confidential spaces, as well as opportunities for learners to share their concerns vis-à-vis their preceptors in a timely manner. This issue is particularly heightened in the context of palliative care education, where debriefing sessions after a home care visit often occur in a preceptor’s vehicle, leading to a sense of powerlessness among learners in speaking up about issues. Some participants shared that underrepresented or internationally trained learners may have important feedback that could help improve the care preceptors provide to other underrepresented or new immigrant populations by sharing knowledge from their own lived experiences, particularly after observing poor intercultural care being delivered. However, they expressed that sharing their perspectives requires the creation of these intentional spaces for dialogue and offering such unprompted feedback without the necessary conditions of relational safety and invitation to exchange ideas from their preceptors puts learners in a precarious situation. Although efforts have been made to improve bidirectional anonymous feedback in medical education, such as through the completion of preceptor and rotation evaluations, there is a lack of transparency on what action is taken to address said feedback. Moreover, in many academic institutions these evaluations are submitted at the end of rotations and, thus, there is often no space held for immediate feedback around clinical encounters. To address these issues, participants expressed an urgent need to build a culture around respectful, open, and ongoing bidirectional feedback, to effectuate dynamic learning among both learners and preceptors without fear of repercussions.

Microaggressions hurt all, we need training to address them effectively

Participants that came from underrepresented populations discussed lived experiences of micro- and macroaggressions. These participants noted that the psychological impact of microaggressions often outweighed that of macroaggressions. They frequently mentioned that after experiencing an act of microaggression from patients, patients’ caregiver, or other members of the health care team, particularly as trainees, they struggled with feelings of doubt and confusion, questioning the validity of their experiences: “Did it really happen? Is it just me? Did anyone else see or hear that?” This form of gaslighting, participants expressed, alienated them. Other participants expressed that microaggressions were not deliberate and may often arise because of a lack of knowledge and experience in cross-cultural communication. However, for learners, particularly in the home care and end-of-life training environment, being unable to seek validation for their experiences created a distance between them and the profession, giving them a sense that they did not belong in palliative care and making it even more challenging for them to address these issues openly.

When encountering moments of microaggressions, newer staff expressed feeling a greater sense of responsibility to support learners quickly. These staff often had a better read on moments that made learners feel like outsiders because they too were so recently in that scenario. As such, they shared that they felt more confident in using their power as a staff to name microaggressions and macroaggressions immediately when they occurred. In comparison, more seasoned staff grappled with how best to use their position to support people using an EDI lens. They felt a complex dynamic around being viewed as overusing their power, crossing boundaries, or reinforcing the patriarchy even when their intentions were to support social justice. The desire to maintain responsibility and accountability toward colleagues, junior staff, institutional heads, and learners often led to seasoned staff feeling “analysis-paralysis.” This in turn, made it challenging for them to proactively respond to witnessing microaggressions even though they felt moral distress in said moments. In effect, senior staff expressed feelings of dissonance when recognizing injustice but not being able to thoroughly acknowledge and address issues, feeling internal conflict and tension about how to balance their support to all people involved. Thus, alongside the need for urgent training to recognize and address microaggressions in real time, participants expressed the importance of establishing an environment where it is the organizational norm that at all levels, all angles of bias are named in a respectful manner and there is an expectation for critical dialogue that fosters shared learning and encourages organizational unity and purpose. Participants also expressed that an environment that allows immediate recognition and discussion of witnessed microaggressions is important for validating experiences and creating a culture of openness, accountability, and respect.

A silent culture maintains the status quo, preventing growth among all

Another salient idea highlighted by participants was that injustice continued to be perpetuated in medical education because of a culture of silence and willful ignorance. This culture, participants expressed, is the result of a guise of harmony. For example, because Canada is perceived as a champion of EDI, a natural thought is that ‘we are doing well in response to issues on inequities.’ However, participants discussed how current EDI frameworks are being implemented superficially (e.g., “how many seats should we allocate to learners that come from Indigenous, Black, and LGBTQIA2 + communities?”), and not in a meaningful intersectional manner (e.g., “how do we account for people with complex identities who are perceived as having privilege based on how they are labeled by others but actually experience unnamed, silent battles?”). Moreover, when issues around systemic bias are specifically named in palliative care education, for example with Black, Indigenous, Muslim, or Jewish learners, a desire to maintain the illusion of peace is prioritized over engaging in difficult dialogue. Although avoidance attempted to diminish conflict, such approaches only served to perpetuate tension and misunderstandings, fueling further divisiveness and reinforcing siloed factions. Avoidance of complex dialogue exacerbated anxiety and isolation, leading underrepresented learners to question their belonging in medicine. Challenging dialogues that embrace conflicting and diverse views require tremendous skill and courage to lead. However, all participants described such dialogues as integral to creating a healthy culture of belonging and growth.

Using one’s power to act, while addressing EDI notions, is perplexing

The question of how to use power for good was brought up in all discussions. Mention was often made to the importance of acknowledging one’s privilege based on both role and identity. However, how one could practically use their privilege to support others remained unclear to most. In other words, participants expressed wanting to use power for others, rather than having power over others, but the method by which they could do this was unclear. Again, concerns around navigating issues using an EDI lens were mentioned as hindering those who held positions of power from being able to communicate openly with others. Some questions and statements that participants mentioned in this regard were:

“How does one decide who is the most vulnerable in a particular situation?”; “Vulnerability is complex, for example you may be labeled as having power because you’re successful, but when you’re also the sole person battling a challenging issue for the greater good and you also happen to be a conventional target who others would like to see fail, your so called “status” is not protective instead you become the most vulnerable in the room”; “How can I act without negatively harming my relationship with my colleagues and junior staff?”, and “What institutional policies must I be aware of when responding to these situations—is there a guide for difficult conversations like these in medical education?”

In response to these, some participants expressed an ethical responsibility to primarily protect learners, particularly due to their vulnerable positionality as medical students or residents. Others expressed that, when using an intersectional lens toward vulnerability, an underrepresented female physician may be more vulnerable than a learner depending on the learner’s sociodemographic and nuanced cultural-religious context, thus putting them in a situation that could be challenging to navigate, despite being the preceptor. When participants shared concrete examples of experienced challenges vis-à-vis positionality and vulnerability, mention was made by a few that those in leadership roles may favor protecting their colleagues and staff over learners. Leaders expressed that adopting rigid communication and feedback structures helped them protect themselves in such situations. Paradoxically, some noted that it was precisely this self-protective strategy that prevented important growth conversations. Conclusively, a need for improved training opportunities was recognized among clinical preceptors and leaders in medical education to better understand how to utilize their power to build safe environments that protect and enable open and honest communication between all. Our analysis favors critically assessing each nuanced situation with openness and curious dialogue over the application of any rigid framework that makes presumptions about the complex, dynamic nature of power.

Discussion

Through a series of dialogical sessions with learners, preceptors, and institutional leaders, we highlight several salient challenges in the context of Canadian graduate medical education, with specific attention to palliative residency. Specifically, we discuss: the systematic de-prioritization of learners in complex clinical settings; the lack of training preceptors receive, particularly to engage in cross-cultural education; the lack of safe spaces and opportunities for bidirectional feedback and learning; the continued existence of microaggressions in medical education and their impact on underrepresented learners; how fear of conflict and the desire to maintain a superficial sense of harmony has detrimental impacts on growth; and how prevalent perceptions of power dynamics and navigating concerns using an EDI lens can be perplexing, hindering leaders from efficiently addressing challenges in fear of doing more harm. To address many of these challenges, all participants wanted to see a shift in culture where open, honest, respectful, and timely conversations can be had without fear or repercussions with a clear purpose in mind—bidirectional growth for both learners and preceptors and a creation of a learning space that is inclusive and unified rather than silent and siloed.

Importantly, participants emphasized that no one intends to be unjust in the medical education context. Learners seek to become excellent clinicians who serve their patient populations well. Preceptors seek to care for patients and educate learners using the approaches they are most familiar with and those they find worked best for them based on their lived experiences. Institutional leaders want to serve their patients, colleagues, and learners with a high degree of accountability and compassion. However, our findings suggest that the reason underrepresented learners and preceptors continue to experience exclusion and harm is because the current model of medical education is unprepared to skillfully support the increasing diversity present in our system. Adversity toward diversity has always existed in medical education.^1,23–25 However, in the past, acculturation of others to the status quo may have been simpler due to the more homogenous population in the health care workforce in the past.^26,27 Now, with almost half of the Canadian population being composed of first- and second-generation immigrants, alongside increased calls for diverse learners being recruited into medical programs, it is evident that our conventional ways of teaching and functioning are being challenged. Thus, just as we are advancing patient-centered care, we must reflect on what learner-centered education could look like in the context of a diversity-infused medical education landscape. For example, does the idea of debriefing in a preceptor’s vehicle after a home care visit bode well with all learners? How can we intentionally invite and empower diverse learners to help us create spaces that enable fruitful discussions and bidirectional learning? If we truly ascribe to the idea that we are life-long learners, how can we build comfort in being ‘the educators’ and still be able to learn from our trainees?

Our article also expresses how current understandings and approaches to EDI in medical education can be convoluted. A key goal of EDI frameworks in medical education is to promote social justice by ensuring everyone is treated fairly while creating spaces where all individuals can thrive. However, our article highlights how current approaches to EDI in medical education can be convoluted and therefore its operationalization presents several challenges. On one extreme, identity can be understood in superficial, rigid terms where a single benchmark is used to guide strategies.^28,29 On the other extreme, heavier intersectional approaches risk fragmenting sociodemographics to the point of paralysis.^30,31 In both cases, EDI efforts can obscure experiences of exclusion and harm. This dynamic is particularly concerning in moments of rising prejudice and discrimination against communities whose marginalization has historically been rendered invisible, dismissed, or inconsistently recognized within dominant EDI frameworks. The process of applying such dominant frameworks in medical education is further complicated by the reality that conventional EDI approaches were largely developed through individualistic ideologies that may not fully account for collective, cultural, or faith-based dimensions of identity and belonging.^32,33 We remain firm in our belief that humane, thoughtful EDI work is essential for individuals, systems, and societies to advance with justice, especially in the current climate where profound misunderstandings prevail and EDI initiatives have been revoked.^34–36 However, there is a need to reflect on how we can better address challenges identified using a contemporary EDI lens that centers on unity over divisiveness and effectuates meaningful change that improves diverse leaners’ ability to thrive and belong in an increasingly complex medical education system.

To better understand how we can respond to the increasing diversity we are seeing in medical education and health systems, we posit that we must shift away from our current models, which have been built on hierarchal and individualistic philosophies of thought and action. In this regard, one approach to help advance medical education and EDI is the concept of “unity in diversity.”^37,38 Just as different notes blend to make a perfect chord, or how the various cells, organs, and systems of the body function together to enable creative thought and action, “unity in diversity” advances the importance of both cherishing the value of the individual and collaborating to advance the collective. This orientation empowers people by recognizing that all are protagonists (i.e., active agents), not simply stakeholders (i.e., a widely used, anti-Indigenous word that has become synonymous with being a passive recipient). Furthermore, this orientation allows us to recognize and celebrate individual differences (e.g., through categorizing vulnerability and partitioning human identity), and concurrently gives us an impetus to think about how we can come together more harmoniously and holistically to better serve a collective purpose (e.g., care for diverse patients and populations with excellence). In this orientation, we are actively called to recognize that microaggressions are a symptom of a defective social order, and a drive exists among all protagonists to jointly learn to do better, thus promoting a greater sense of comfort with engaging in difficult discussions in an open and respectful manner for the sake of building trust and mutual growth.

In conclusion, through a critical and reflective dialogical process that engaged clinical learners, preceptors, and institutional leaders on conversations around experiences and perspectives of EDI in medical education, we begin to see how a paradigm centered on individualism and power hierarchies facilitates an environment where injustice is systematically ingrained and reproduced in a multitude of complex ways. In such a context, protagonists feel incapable of addressing microaggressions, let alone systemic challenges, leaving all feeling distress and alienation, and underrepresented learners experiencing isolation. In this perspective piece, we share strategies that can be implemented across medical education to address immediate issues, as well as share the importance of explicitly critiquing and revising our philosophical orientation, such that we can truly advance ‘unity in diversity’ and work toward the elimination of discrimination across medical education and health systems at large.

Authors’ Contributions

A.K.A. supported the interpretation of field notes and led the writing of this article. M.F., S.B., and M.O. all supported the conceptualization, field note collection, and writing of this work. R.M. led this study team, acquired funding to support A.K.A. and M.F. as well as supported the conceptualization, field note collection, and writing of this work. All authors read and approved the final article.