Cultural complications: Why, how, and lessons learned.

Medicine had always been a paradox. Our most cherished ideals are those that weave together compassion, knowledge, and skill in the promise of relieving suffering and preserving human dignity. At the same time, the medical community has wielded these very tools to codify what bodies have worth, which individuals deserve care, and even which members can rise through our ranks.1, 2, 3 As the toll wrought by twin pandemics, COVID-19 and police violence, make salient the consequences structural racism has always had for Black and Brown people, medicine has been forced to turn inward. , In our reflection, we see the uncomfortable truth: bias, in our systems, in our patients, and in ourselves influence every aspect of care.

As we have begun to recognize our own pathology, the question becomes how do we heal? Institutions have rushed to bolster their Diversity, Equity, & Inclusion (DEI) offices, professional societies have published position papers, and health care workers have splashed pledges to combat racism across social media. These are important first steps, but the potential space between a perfunctory ‘diversity check box’ and meaningful change can remain large. Furthermore, practical questions regarding what training should look like, who should lead these initiatives, or how to balance education and action remain. Undoubtedly, there are many ways to evolve hospital culture, and durable change will need to be multifaceted.

Based on our own institutions’ shortcomings, and with the goal of creating lasting cultural change, we have developed and implemented a program to help departments take their first steps: A Cultural Complications Curriculum (www.culturalcomplications.com). Our guiding principle is that cultural error should be addressed with the same rigor we apply to medical error. The Cultural Complications Curriculum leverages a standard Morbidity & Mortality conference format (e.g. case presentations, brief didactic sessions, group discussion) and adapts it to discuss instances of cultural breakdown. By anchoring our approach in a combination of cases and didactics, we hope to galvanize our audience around a belief that core DEI issues such as racism, sexism, homophobia etc. are a reality of daily hospital life, while providing them with a robust scientific basis to understand and respond to these challenges.

In this perspective, we discuss valuable lessons across each stage of deployment that may guide institutions hoping to embark on similar initiatives. In particular, by thinking critically about why diversity training fails, who comprises our target audience, and what we are asking of our participants, we have been able to refine our approach.

Setting the stage for successful implementation

Leverage your context. Although scholarship and advocacy around health disparities or bias is not new, such concerted attention and support for these initiatives is unprecedented. Ideally, it would not take a national crisis to spur such vigorous commitments, but as long as resources are finite and attention spans short, DEI advocates must work to secure funding, time, and formalized leadership now, while administrators are eager to demonstrate progress. At the same time, individuals hoping to do this work, particularly those in more junior positions, will benefit greatly from partnering with a local champion. Change is hard, and may be particularly unwelcome when it comes to matters such as identity or institutional bias. Enlisting a prominent leader outside the expected DEI space to both introduce and support your initiatives, sends a powerful message that the work is valued.

Selecting your forum. In our fervor to implement successful DEI initiatives, we must also be careful to dispel the notion that something is always better than nothing. The average clinician has heavy demands on their time and programs adding to this burden will face intense scrutiny. Similarly, large-scale analyses from the business sector consistently demonstrate compulsory diversity training can actually increase bias by reinforcing stereotypes, or even spark backlash when participants feel they are being forced to attend low-value sessions. , At the crux of these unintended consequences is the fact that employees are able to differentiate between a performative exercise and an authentic investment in culture.

In this context, leveraging M&M conference has several advantages. First, it is a regular and pre-existing commitment, introducing no new demands on participants’ time. Second, it is one of the few forums where all levels of a departmental hierarchy congregate. Although resident or medical student education time may be more accessible, relegating DEI work to trainees both ignores knowledge gaps faculty members harbor and sends a tacit message that the content is not compelling enough for everyone. Third, integrating the Cultural Complications Curriculum into a conference that is devoted to rigorously addressing error helps avoid the performative trap. Finally, its longitudinal natural reinforces the idea that cultural transformation is a continuing effort, and not something that can be accomplished in a single afternoon.

Understanding you audience. In entertaining the possibility of unintended consequences, it is also instructive to think critically about your audience. The aforementioned diversity training analyses provide most of their results in aggregate. However, our experience suggests that this cohort is not monolithic, and the standard M&M audience likely exists on a spectrum across four major subgroups:

The Early Adopters: people who enlist in voluntary training and are actively doing DEI work

The Sympathetic but Inactivated: people with baseline knowledge about core DEI topics, but who are unsure how to translate this knowledge into action

The Unaware or Skeptical: people who have limited knowledge or may be reluctant to believe bias/inequality/discrimination is a widespread problem or a problem at their own institution

The Actively Resistant: those who do not believe these issues are a problem and are unwilling to change

Dividing the audience in this manner helps up better conceptualize individuals’ likely pretest willingness to participate in diversity training, and helps clarify both who are our targets should be, and what tone may be most effective. The Cultural Complications curriculum aims to focus on groups 2 and 3 believing these are the largest subsets and those with the most potential for change.

Know your gatekeepers, anticipate detractors, invite them in. Prior to deployment, we encourage advocates to be deliberate in identifying potential detractors. Although prominent support and clear data may be helpful, it will not convince everyone. Vocal dissent during the session can create a chilling effect, stymying future discussion, especially if there is a power differential between the presenter and the detractor. One strategy to overcome this risk is to ask DEI mentors to identify potential critics early, and then with the help of allies in your leadership, invite these individuals to be part of your team. Proactively soliciting cognitive diversity has helped us identify areas where our argument is weak, and gives individuals a platform to voice their concerns in a more controlled setting. In fact, encouraging differing opinions and responding thoughtfully to criticism may be the best way to transform an adversary into an ally.

An inclusive approach to deployment also helps mitigate situations wherein (potentially skeptical) gatekeepers feel their authority to moderate content is unfairly compromised to accommodate change. This may be particularly important for integrating the curriculum into conferences steeped in tradition, or if you are asking for time from a session moderated by someone outside of you team. In the rare instances where strong high-level opposition persists, working to identify a different context (e.g. a smaller or more focused forum) to deliver the content, may be an appropriate compromise.

Delivering the content

Preparing & delivering the session. When deciding who should administer the content, you must also be sensitive to the onus of participation. Academic medicine remains a largely homogenous environment, so when addressing DEI issues, the natural tendency may be to repeatedly draw from a small group of early adopters. This recurrent demand is taxing in and of itself; however, asking members of your community to highlight aspects of their identity they may actively try to downplay can be unfair, and in some environments, unsafe. With this in mind, a small group of trusted and willing allies may be best to deliver the content initially, but eventually leaders should broadly distribute the work, just as they would for any other educational curriculum. Some organizers may feel their department lacks the expertise to deliver DEI content or discuss solutions or best practices to the scenarios. In this case, we encourage leaders to invite experts from outside the department to comment on the case or discussion, just as they might do for a clinical complication (i.e. inviting an obstetrician to comment on a case involving a pregnant patient). Keep in mind, DEI scholarship is constantly evolving and expertise will always be imperfect, so a willingness to learn and acknowledge error will be more important that an exhaustive knowledge base.

Cultivate Useful Participation. Depending on the culture of your institution as a whole, and M&M specifically, DEI leaders must be prepared for the possibility that cultivating useful discussion may be challenging. Some audience members may fear that they will be penalized for asking questions or saying the wrong thing, whereas others may fear retaliation for speaking about personal experiences. Our experience demonstrates that some of these concerns can be mitigated by providing standardized cases (supplied in our online case bank), which prevent specific individuals from being implicated as perpetrators, and avoids relying on audience members to supply traumatizing experiences. We have also found that early in deployment, it may be helpful to provide select audience participants with the scenarios ahead of time, so that they can prepare a thoughtful question or response that can jumpstart the discussion and demonstrate participation is welcome.

What remains a work in progress, is how to most effectively translate these discussions to a virtual platform. The detached nature of video conference may deter participants from delving into personal experiences. On the other hand, many virtual platforms have chat functions that allow participants to ask genuine questions anonymously. Although moderating these questions for a larger audience may require some diplomacy, removing a layer of judgement may facilitate richer conversation. Furthermore, chat functions keep notes in real time, allowing organizers to compile and distribute best practices for combatting bias in the workplace, and will hopefully enable our research team to collate these strategies across institutions.

Another possible advantage of a virtual platform may come from built-in anonymous polling functions (e.g. how many of you have experienced a microaggression similar to this?). Real-time data that demonstrates a large percentage of the audience has encountered a given cultural complication may illustrate that the problem is both real and widespread, thus strengthening participants’ commitment to action. Relative to a ‘raise your hand if you have ever experienced [x]’ approach, virtual polling adds another layer of safety through enhanced anonymity. Moreover, as departments shift an increasing portion of their business online, virtual settings may offer new opportunities to correct behavior (e.g. a participant can notify the moderator privately that a comment was inappropriate) and this can be addressed in a more immediate fashion. Organizers should remain cognizant of how they can shape the new digital environment to improve culture, and adapt to their specific institutional needs.

Creating space for debriefing and ongoing discussion. Though we believe one of the strengths of the Cultural Complications Curriculum is that the sessions are succinct, we recognize that 20 minutes is not always enough time to create fully formed solutions. Conversations may spill past the dedicated session and continue between attendants in clinical spaces. In many respects, this is encouraging, and allows for more introverted individuals to lend their voices in a context that is more comfortable for them. However, a few participants at one of the pilot sites have expressed difficulty returning to work after sharing deeply personal, and in some cases traumatizing, experiences. We continue to explore how best to address this need for additional support, whether it be by identifying faculty members who are willing to continue the conversation offline, additional voluntary sessions outside of work hours, or self-education. While the optimal solution is likely specific to the local site, ensuring the institutional culture provides an open and safe environment for continuing the conversation is critical to the curriculum’s success.

Working towards sustainability

Be Willing to Adapt to the Local Context. To sustain change, you must also be willing to adapt. At one pilot institution, an early point of contention in deploying the curriculum was that the sample cases centered largely from the provider’s perspective, and this detracted from M&M’s mission to understand how error impacted patient outcomes. Rather than insisting the two were inextricably linked, we elected to create a second track incorporating patient-specific data and scenarios, and are actively expanding our topic list as participants request content. This approach requires more effort, but ultimately has made our curriculum stronger and more widely applicable. Similarly, DEI champions must also be cognizant of their participants’ needs. For example, institutions that already have robust DEI initiatives may not need to spend much time building a shared knowledge base, and will benefit more from refining their response strategies. Incorporating formalized feedback mechanisms will help administrators tailor their approach to maximize efficiency.

Allow for imperfection. DEI work is ever-evolving, frequently contradictory, and often filled with more questions than answers. As we have attempted to navigate this enormously complex landscape, we have made choices and compromises that others may not. Chief among them, has been our decision to largely avoid any moralistic or social justice language. As we discuss in more depth in our introductory webinar (https://www.youtube.com/watch?v=7nBW7bQ5mHA), this choice stems from our decision to direct our content at that middle ‘inactivated to skeptical’ audience member for whom limited data suggests social justice language may lead to disengagement. However, there is a very real argument that such unwillingness to name racism, sexism, homophobia, etc. as the root of these complications blinds us to reality and will ultimately produce solutions aimed at superficial rather than core problems. When to compromise and to what degree depends on the local context. Key gatekeepers may very well have contributed to entrenched power structures reinforcing bias or discrimination; they may not be well-versed in DEI data, or understand the lived experience. In this light, compromise can feel unwarranted. However, our experience has demonstrated that making concessions is important to building a culture of mutual respect. Creating an environment that emphasizes partnership over opposition will allow for ongoing programmatic expansion, particularly once you are able to demonstrate that your work has tangible value.

Accept that this is hard. Finally, we must accept that this work is hard. It is hard to experience or witness bias. It is hard to speak up. It is even harder to simultaneously weather discrimination and be responsible for educating your peers. It is hard to be an ally. It is hard to acknowledge when you have failed in your allyship and commit to doing better. It is hard to ask for help. It is hard to hear your cause criticized or your work disparaged. It can be hard to compromise. It is hard to accept that your knowledge isn’t enough and that there is always more to learn. All of this work is hard, but it is also necessary, and it is worth it, and it is time.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors have no financial and personal relationships relevant to the current work to disclose.