408 - The Summer 2021 Teaching Edition: Microinterventions, Orienting New Learners, & Optimizing Clinical Learning Environments

From the American Psychologist

1) Disarming Racial Microaggressions: Microintervention Strategies

In our recent Winter Teaching Edition ( Link to Download ), we talked about microaggressions and defined four subtypes: microassaults, microinsults, microinvalidations, and environmental microaggressions. The word microaggression was initially coined by Harvard psychiatrist Chester Pierce in 1970 and referred to minor yet damaging humiliations and indignities experienced specifically by African Americans. The modern definition of microaggressions describes them as “subtle snubs, slights, and insults directed towards minorities, as well as to women and other historically stigmatized groups, that implicitly communicate or at least engender hostility.” This definition extends beyond verbal abuse to include general disrespect, devaluation, and the exclusion of recipients. Microaggressions occur daily and are commonly delivered automatically and unconsciously with dismissive body language or tone of voice.

So, you encounter a situation where a microaggression has occurred - now what? An article in the American Psychologist outlines four interventions that people of color, white allies, and bystanders can use to disarm microaggressions.

Microinterventions are defined as the everyday words or deeds, whether intentional or unintentional, that communicate to targets of microaggressions (a) validation of their experiential reality, (b) their value as a person, (c) affirmation of their racial or group identity, (d) support and encouragement, and (e) reassurance that they are not alone. They are interpersonal tools that are intended to counteract, change or stop microaggressions by subtly or overtly confronting and educating the perpetrator.

1. Make the “Invisible” Visible: Name the oppressive event. It is often much easier to pinpoint microaggressions that are explicit (hate speech, for example) because there is little to speculate about the intent. Many microaggressions, however, have both a conscious communication and hidden communication that is outside the level of the perpetrator’s awareness - naming an oppressive event when it occurs offers the opportunity for the initiator to be completely aware of the hidden bias their words/actions present. “Wow, your English is so great!” “Thank you, I hope so. I was born here.”
2. Disarm the Microaggression: Stop or deflect oppressive comments or actions through expressing disagreement, challenging what was said or done, and/or pointing out its harmful impact. “That comment was inappropriate - I really don’t appreciate talk like that.”
3. Educate the Offender: While education is a long-term process, microinterventions are the building blocks to better awareness that may lead to personal growth over time. Educating the offender can be intimidating - when microaggressions are pointed out, many offenders shift to focusing on intent rather than the action. Refocus the conversation to discussion on impact rather than intent. “I know you didn’t mean it that way, but it was hurtful when you _____ because ______.”
4. Seek External Intervention: There are times in which individual efforts to respond to microaggressions may be contraindicated, ignored, or ill-received. Sometimes, the most effective approach is to seek external support from others or from institutional authorities. A discriminatory act or repeated oppressive behavior by a manager may best be handled by reporting to a higher authority.

Hannah’s Comments:

The team of authors created a helpful visual to offer a list of microintervention strategies to implement in various contexts: directed toward individual perpetrators, toward institutional macroaggressions, and towards societal macroaggressions. Check out the chart in the link referenced below.

Reference:

Sue, DW, et al. (2019). Disarming racial microaggressions: Microintervention strategies

for targets, White allies, and bystanders. American Psychologist, 74(1), 128–142. Link

From Teaching Physician

2) Orienting a Learner on Their First Day

First impressions are important -- the first day of a new learner’s rotation with you sets the foundation for their entire experience. When the learner arrives, meet with them to outline proper expectations and provide an introduction to the team and the clinical space. Beyond getting to know one another, helpful agenda topics for this first meeting are: outlining one another’s expectations, setting avenues for feedback, and reviewing goals.

Outlining expectations:

• Together, skim through the evaluation forms you need to fill out at the end of the rotation for their school/program. This way, you both are aware of any specific educational needs or requirements. This will also help you both understand how the learner will be evaluated.
• Review any office policies that are relevant to the learner.
• Define the level of involvement that is expected with patients, the anticipated patient load, and when the learner should involve you.
• Let the learner know the characteristics of the patient population your office sees.
• Discuss guidelines and expectations for documentation and presentations.

Setting avenues for feedback:

• How often will feedback be given? How should the learner give you feedback?
• In what settings will it be offered? Real-time, one-on-one, mid-point meetings?
• What is your feedback style? This is a great time to talk about your supervisory style with the learner.
• Are there any times where it is inappropriate for the learner to ask questions?

Reviewing goals:

• Talk with the learner through each goal to ensure they know what they will and will not have the opportunity to do and to be certain their goals are reasonable for the rotation.
• Ask if they are comfortable sharing these goals with the other clinicians and staff they may be working with and share accordingly.
• If you have goals as an educator, share those with your learner and ask for feedback.

Hannah’s Comments:

Other thoughtful tips to make your learner feel at home:

• A few days before the learner arrives, send out an email to your colleagues and clinic staff announcing their arrival with a few fun facts: what school or town they are from, what they do for fun, personal motto, picture if you have one, etc.
• Make sure they know where to park and how to enter/exit the building.
• Give the new learner a tour and introduce them to everyone they’ll be working with (if possible).
• Remember, you’re welcoming them into your practice culture and in many cases, providing them a “first impression” of Family Medicine/Primary Care. For someone new, even knowing about places to get lunch/food are important.

Reference:

Modified from Teaching Physician. Orienting a Learner. Society of Teachers of Family

Medicine. Retrieved from: Link

From the Literature

3) Creating and Optimizing Clinical Learning Environments

In the clinical setting, time is the most cited barrier to teaching. When a learner begins the rotation, it is important to have a process for managing clinical workflow in order to create adequate time for education. By enhancing efficiency, you will be able to teach

and model the multi-faceted areas that are necessary for clinician success. In trying to optimize that learning time, it is recommended to reflect on the learner’s impact on the office flow prior to their arrival.

Consider the following as you manage the clinic workflow:

• Patient and staff perspectives of the learner/their abilities
• How to identify patients who may not want a learner present and how to manage that interaction appropriately
• The amount of time will you allot before going into the room to confirm the history
• How many patients the learner will see each session (ideally)
• Structure of the day (it’s a good idea to meet with the learner and staff in the morning to review)
• Specific aspects of patient care that would provide opportune learning experiences

My Comment:

As you consider your workplace setting, it is important to keep in mind that the learner is consistently entering new learning environments. For many, this can be overwhelming and exhausting. A setting that is welcoming, well-organized, and has clear expectations relieves much of that anxiety and allows for more trust to be built between the learner and the preceptor. The clinical learning environment is powerful - it provides a unique and valuable set of opportunities for instruction that a classroom cannot. Keep that thought top of mind as you consider your role in the learner’s medical education.

References:

• Heidenreich C, Lye P, Simpson D, Lourich M. The search for effective and efficient ambulatory teaching methods through the literature. Pediatrics.

2000;105(Supplement 2):231-7. Link

• Westberg J, Jason H. Collaborative clinical education: the foundation of effective health care. Springer Publishing Company; 1992.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org