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  • Communication

    What Did You Just Say? Fostering Civil Discourse in Medical Education

    Let’s talk about talking.  It seems given the current environment in the U.S., we’re walking on eggshells, not really sure what we can or should say. These challenges with conversing have resulted in a pressure cooker within academic health centers amongst many other places. Stress, long hours, and differing opinions can sometimes lead to terse discourse (1,2). Whether it’s a vigorous debate during rounds, a classroom discussion has gone awry, or a tense exchange between colleagues, communication seems to be broken. The ability to de-escalate conflict and promote respectful conversations is paramount. As medical educators, we must model and cultivate civil discourse to create a positive learning environment and equip future healthcare professionals with essential communication skills.

    Are you still with me?  Good! In Robert Livingston’s book The Conversation (3), he references cognitive heuristics that we use. A heuristic is a tendency to overweight information readily available in your mind when making a decision. As clinicians, illness scripts are a medical application of a cognitive heuristic. You’ve seen many presenting with nearly identical symptoms, so you immediately go to the diagnosis you believe it is. Without additional contrary evidence to sway you, you proceed to treat accordingly (and of course run the risks associated with premature closure).

    Where cognitive heuristics occur in normal discourse, these have been built over time based on an individual’s experiences and knowledge. When confronted, for example, with an initiative related to diversity and inclusion, their heuristics may lead them to believe diversity of thought is a bad thing, something undesirable. Why? Who knows? The reaction may then be the polar opposite of what you expect and will clearly interfere with what you hope to accomplish. This can even occur in simple conversations.

    The bigger question is how can we break this cycle of high-tension communication? How do we gain an understanding and respect of others’ experiences to converse in a civil manner? How can we carry on conversations that seek to find mutual understanding and maintain mutual respect (even if we do not agree)?

    As you can well imagine, there are a lot of approaches described online. When a conversation becomes heated, it’s crucial to act as a calming influence. Here are some techniques to de-escalate:

    • Establish Psychological Safety: Remind everyone that you’re on the same team and want to find a resolution together. Use inclusive language and express a willingness to work through the issue collaboratively.
    • Ask Open-Ended Questions: Encourage reflection and sharing of perspectives. Instead of accusatory questions, try “Can you help me understand your perspective on this?” or “What’s most important to you in this situation?”.

    Finding common ground is essential for moving past conflict and fostering understanding, which is a key premise of Livingston’s book (3). Probably the most important advice offered in several other articles is active listening. Truly listen to understand, not just to respond. You have to avoid the temptation to be contemplating your response when they are speaking. Pay careful attention to the underlying concerns or values being expressed (4,5). Don’t worry if there’s a gap, a brief silence, in a conversation.

    Livingston’s framework for structuring dialogue to promote deeper understanding and collaboration involves asking deliberate, thoughtful questions to elicit information and encourage reflection (3). These are a few that may help:

    • Start with “What Happened?” or “What’s the issue we’re facing?”: Encourage a factual recounting of events or perspectives to establish a shared understanding of the situation.
    • Move to “Feelings”: Ask about the emotions involved: “How did that make you feel?”. Acknowledging feelings can help de-escalate tension and build empathy.
    • Explore “Identity”: Consider how the situation impacts individuals’ sense of self and their role within the group. This can help uncover underlying motivations and perspectives.
    • Examples of Dialogue-Enhancing Questions:
      • “Can you tell me more about how you see it impacting the situation?”
      • “What would a successful resolution look like for you, and how can we work toward that?”
      • “What are some other approaches we could consider here?”

    The house of medicine has to interact with people of varied backgrounds. Although some of those people may not share any of our own values, it is essential to be able to converse with one another in a respectful, caring manner.

    This Med Ed Chat blog is a bit different, but it felt needed in our current environment. Here are some questions for you to consider:

    • How can we, as medical educators, create a culture that encourages open and respectful dialogue, even when discussing contentious issues?
    • What strategies can we implement to ensure that all voices are heard and valued in discussions about diversity, equity, and inclusion?
    • How can we equip future healthcare professionals to navigate and resolve conflicts that arise from differing perspectives and experiences?
    • How can we prepare when someone is intransigent? What might that conversation look like – especially if you’re the intransigent one?

    Thank you for indulging my musings on this topic.

    References:

    1. May H. Create a CULTURE of belonging. HR Future 2022 (6); 46-47.
    2. Medina FJ, Benitez M. Effective behaviors to de-escalate organizational conflicts in the process of escalation. Sp J Psychol 2011; 14(2):789-797.
    3. Livingston R. The Conversation. New York, NY: Currency, 2021.
    4. Del Bel JC. De-escalating workplace aggression. Nurs Mgmt 2003 (9); 30-34.
    5. Albardiaz R. De-escalating emotions: A process. Educ Primary Care 2017; 28(1):54-55.

    Blog Author: Gary L. Beck Dallaghan, Ph.D.; Administrative Director, Alliance for Clinical Education. 

  • Diversity

    Hear Me Out! Inclusion also Includes Deaf and Hard-of-Hearing Medical Students

    Sticking with the theme of our previous MedEdChat blog last month, diversity in the health care workforce in general and undergraduate medical education needs constant attention. Although this is a topic that has been well-researched, one crucial aspect of diversity often remains under-addressed: the inclusion of individuals with disabilities. This blog post explores in general terms why actively training individuals with disabilities is important and specifically focuses on deaf and hard-of-hearing individuals in medicine. 

    In 2018, Meeks and colleagues (1) reported that nearly 20 percent of the US population has a disability. Many of these individuals face healthcare disparities due to a lack of understanding of their challenges by their providers. One example noted that many primary care settings lack appropriate exam tables, weight scales, and restrooms for patients with disabilities (2). Although studies have identified the benefits of a workforce that embraces diverse healthcare providers, relatively few individuals with disabilities work in medicine. Moreso, only 2.7% of medical students disclose disabilities, 10% of which have apparent disabilities and 90% do not (2). 

    To be totally transparent about why this blog focuses on deaf and hard-of-hearing (DHoH) individuals entering medicine, I was a sign language interpreter for nearly 25 years and also have a prominent hearing loss. The most obvious benefit for more DHoH providers in medicine is the ability to communicate directly with patients. As McKee and colleagues (3) also point out, DHoH physicians enrich the medical education experience by fostering greater disability awareness among their peers and faculty. Increased awareness translates to a better understanding of how to interact with and care for DHoH patients and their families, ultimately improving patient care and outcomes (1). Furthermore, DHoH professionals offer unique perspectives and lived experiences that can lead to innovative approaches in UME, patient care and healthcare delivery (3). They can also serve as role models and advocates for their community, fostering greater trust and engagement between healthcare providers and DHoH patients (4).

    Despite the clear benefits, DHoH individuals remain underrepresented in medical schools and the physician workforce (4). This underrepresentation is often attributed to systemic barriers, including biases in application processes, a lack of inclusive educational opportunities, and insufficient accessibility support (5,6). As Meeks et al. (5) note, disability is often an “unexamined diversity,” with many institutions lacking comprehensive policies and practices to support students with disabilities. Although universities provide central disability resources, the unique demands of medical education programs challenge these offices (6).

    Additionally, the Liaison Committee on Medical Education standards stipulate every school has technical standards (7). Even in light of the Americans with Disabilities Act, the Standards are often written in ways that do not take into consideration individuals with disabilities. If a school expects that all students, for example, can use a stethoscope and appreciate rales and murmurs, what accommodations are made for someone with profound hearing loss? If the school expects all students to perform “inspection” as part executing a physical exam, how can one accommodate a blind person?

    The inclusion of DHoH individuals in medicine has far-reaching benefits. It not only improves healthcare access and quality for the DHoH community but also strengthens the medical field as a whole. A diverse physician workforce brings unique perspectives, problem-solving skills, and lived experiences that enhance medical training and research (8). By embracing diversity, the medical field can better reflect the communities it serves and provide more equitable and effective care for all.

    What do readers think? How can we address the following questions?

    1. How does inclusion of DHoH individuals in medical education programs challenge admission and accreditation standards for medical schools? Specifically, are technical standards essential for the practice of medicine truly essential? Can they be modified?
    2. How can medical educators and advisors become better equipped to support students with disabilities in rigorous and fast-paced programs?
    3. What are the potential long-term benefits of having more DHoH doctors in the healthcare workforce for both the medical community and patients?

    Give us your thoughts!

    References

    1. Meeks LM, Herzer K, Jain NR. Removing Barriers and Facilitating Access: Increasing the Number of Physicians With Disabilities. Acad Med. 2018 Apr;93(4):540-543. doi: 10.1097/ACM.0000000000002112.
    2. Mudrick NR, Breslin ML, Liang M, Yee S. Physical accessibility in primary health care settings: results from California on-site reviews. Disabil Health J. 2012 Jul;5(3):159-67. doi: 10.1016/j.dhjo.2012.02.002.
    3. McKee MM, Smith S, Barnett S, Pearson TA. Commentary: What are the benefits of training deaf and hard-of-hearing doctors? Acad Med. 2013 Feb;88(2):158-61. doi: 10.1097/ACM.0b013e31827c0aef.
    4. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013 Feb;88(2):224-32. doi: 10.1097/ACM.0b013e31827c0d60.
    5. Meeks LM, Case B, Stergiopoulos E, Evans BK, Petersen KH. Structural Barriers to Student Disability Disclosure in US-Allopathic Medical Schools. J Med Educ Curric Dev. 2021 May 26;8:23821205211018696. doi: 10.1177/23821205211018696.
    6. Meeks LM, Case B, Herzer K, Plegue M, Swenor BK. Change in Prevalence of Disabilities and Accommodation Practices Among US Medical Schools, 2016 vs 2019. JAMA. 2019 Nov 26;322(20):2022-2024. doi: 10.1001/jama.2019.15372.
    7. Liaison Committee on Medical Education. Functions and Structure of a Medical School, 2025-26. Available at https://lcme.org/publications/. Accessed February 19, 2025.
    8. Meeks LM, Plegue M, Swenor BK, Moreland CJ, Jain S, Grabowski CJ, Westervelt M, Case B, Eidtson WH, Patwari R, Angoff NR, LeConche J, Temple BM, Poullos P, Sanchez-Guzman M, Coates C, Low C, Henderson MC, Purkiss J, Kim MH. The Performance and Trajectory of Medical Students With Disabilities: Results From a Multisite, Multicohort Study. Acad Med. 2022 Mar 1;97(3):389-397. doi: 10.1097/ACM.0000000000004510.

    Blog Author: Gary L. Beck Dallaghan, Ph.D.; Administrative Director, Alliance for Clinical Education. 

     

    Blog Response – February 19, 2025:

    1. How does inclusion of DHoH individuals in medical education programs challenge admission and accreditation standards for medical schools? Specifically, are technical standards essential for the practice of medicine truly essential? Can they be modified?

    Yes, technical standards are essential and important; however, they must be written so they are not exclusionary.  For example, instead of using the sensory words like “hear” and “see” the tech standards should say “communicate” or “observe”; in other words, the TS should say what needs to be accomplished without stating how the task should be accomplished.  Also include that TS can be accomplished with accommodations when the accommodations do not equal a fundamental alteration. 

    1. How can medical educators and advisors become better equipped to support students with disabilities in rigorous and fast-paced programs?

    Partner with your disability services office; attend disability related professional development sessions/workshops; invite experts (including disabled students) to speak to faculty and staff.  Invite in doctors with disabilities to speak about strategies that were important for them to progress through med ed. 

    1. What are the potential long-term benefits of having more DHoH doctors in the healthcare workforce for both the medical community and patients?

    Understanding a person’s lived experiences is important to provide the best possible care.  Having lived those or similar experiences gives a doctor an advantage in treating patients by allowing a level of knowledge others without such experiences may not have.  As human beings live longer, the population of those with hearing loss will continue to grow.  The long term positive impact of D/d/HH doctors is essential to address the needs of these individuals. 

    Note:  “D” is for those who  consider deafness their culture and don’t consider themselves disabled.  “d” is those who are deaf, but don’t consider deafness their culture.  HH is hard of hearing.  Important terminology to include when speaking about these populations.

    Cindy Poore-Pariseau, Ph.D.; Director, Office of Disability Services, Rutgers Health

  • Diversity

    Diversity and Inclusion in #MedEd

    Medical education is facing many serious challenges. Specific to diversity, equity and inclusion (DEI), as some states are passing legislation limiting discussions related to DEI, attempts to educate medical students about the spectrum of patients they may see faces scrutiny. What has caused this backlash towards DEI initiatives? 

    As a key aspect of helping students develop (or enhance) their cultural humility, DEI programs encompass broad concepts aimed at fostering inclusive environments where all individuals feel respected and valued. Diversity encompasses representation of different identities and backgrounds, including race, gender, ethnicity, age, and more. However, diversity is not limited to ethnic or racial groups but extends to all aspects of individual identity and experience [1,2]. Equity is the process of ensuring fair treatment, access, and opportunities by acknowledging and addressing systemic disparities that disadvantage certain groups [Coulter et al]. Inclusion is the practice of creating environments where diverse individuals are fully integrated and empowered to participate. In healthcare education, for instance, DEI principles are integral for promoting culturally responsive care [3].

    Evidence does, however, suggest that overly narrow definitions of DEI can inadvertently lead to exclusion. One major criticism is that focusing on specific groups can consequently neglect other marginalized communities, such as those with disabilities, those from low socioeconomic backgrounds, or sexual and gender minorities [1,2]. For example, in educational settings, when curricula focus on race but fail to integrate discussions on class or gender, certain students may feel marginalized or excluded from the conversation. This limitation is a reminder that inclusivity must be intersectional and address the diversity within groups. The very definition of intersectionality recognizes the interconnectedness of social categories, such as race, disability, gender, socioeconomic background, etc.

    There is also concern that DEI efforts can sometimes unintentionally reinforce stereotypes, particularly when diversity is taught as static characteristics of groups rather than acknowledging the dynamic nature of individual identities [2]. This may lead to historically majority groups feeling excluded and unwelcome in conversations [4].

    Research suggests that well-designed DEI initiatives positively impact learning environments by enhancing cultural competence, reducing bias, and preparing students for diverse patient populations. Studies indicate that the integration of anti-racism education in medical curricula leads to increased student awareness of health inequities and promote critical thinking about the social determinants of health [5,6]. Students who undergo such training are more likely to recognize their innate biases and demonstrate greater empathy in patient care [1,3]. 

    However, DEI initiatives currently face resistance in municipalities, states and even the Federal government. The attacks on DEI impact the learning environment where students feel defensive or disengaged [6,7]. Ultimately this resistance may result in even worse patient outcomes due to inadequate training.  

    To truly foster an inclusive learning or work environment, institutions must promote dialogue that brings together contrasting viewpoints in a psychologically safe setting, maintaining respect and empathy. One strategy is to create safe spaces for open discussions, where students and faculty can critically reflect on their biases without fear of judgment. For instance, some studies have shown that integrating cultural humility and critical consciousness frameworks into curricula encourages lifelong learning and introspection [3,8].

    Additionally, engaging diverse stakeholders, including students, faculty, and community members, can ensure that multiple perspectives are considered when designing DEI initiatives [4,6]. Continuous faculty development is also critical for ensuring that educators have the skills and confidence to address complex social issues in the classroom [7]. Embedding DEI principles throughout the curriculum, rather than treating them as stand-alone add-ons, helps normalize discussions around diversity and equity in everyday practice [2].

    DEI, when implemented thoughtfully, has the potential to transform learning environments by promoting inclusion, reducing bias, and fostering a culture of empathy. However, for DEI initiatives to be truly inclusive, they must be intersectional and comprehensive, addressing the needs of ALL groups while ensuring that no one feels excluded. Ongoing reflection, stakeholder engagement, and faculty development are critical to ensuring these initiatives have a lasting and positive impact on the learning and work environment.

    What do you readers think?  How can we address the following questions?

    1. How can medical education strike a balance between promoting inclusive environments through DEI initiatives while ensuring that NO groups feel alienated in the process?
    2. As DEI initiatives face increasing resistance due to political and cultural shifts, what strategies should medical educators adopt to create open, respectful dialogue on DEI issues without violating institutional or state restrictions?

    References

    1. Coulter E, McQueen C, Abu-Jurji Z, Chan-Emery I, Rukavina M, Solecki R, Wojkowski S, Dhir J. Development and delivery of justice, equity, diversity, inclusion, and anti-oppression concepts in entry-level health professional education: A scoping review: BEME Guide No. 88. Med Teach 2024:1-13. doi: 10.1080/0142159X.2024.2387147.
    2. Dogra N, Reitmanova S, Carter-Pokras O. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach 2009; 31(11):990-993. doi: 10.3109/01421590902960326. 
    3. Van Liew JR, Lai C, Streyffeler L. Twelve tips for teaching culturally and socially responsive care to medical students. Med Teach 2024; 46(10):1278-1283. doi: 10.1080/0142159X.2024.2322713.
    4. Livingston R. The Conversation: How Seeking and Speaking the Truth about Racism Can Radically Transform Individuals and Organizations. New York: Currency, 2021.
    5. Nathan AS, Del Campo D, Garg PS. Where are we now? Evaluating the one year impact of an anti-racism curriculum review. Med Teach 2024:1-6. doi: 10.1080/0142159X.2024.2316852.
    6. Binda DD, Kraus A, Gariépy-Assal L, Tang B, Wade CG, Olveczky DD, Molina RL. Anti-racism curricula in undergraduate medical education: A scoping review. Med Teach 2024:1-11. doi: 10.1080/0142159X.2024.2322136.
    7. Racic M, Roche-Miranda MI, Fatahi G. Twelve tips for implementing and teaching anti-racism curriculum in medical education. Med Teach 2023;45(8):816-821. doi: 10.1080/0142159X.2023.2206534. 
    8. Dogra N, Bhatti F, Ertubey C, Kelly M, Rowlands A, Singh D, Turner M. Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103. Med Teach 2016; 38(4):323-37. doi: 10.3109/0142159X.2015.1105944. 

    Blog Author: Gary L. Beck Dallaghan, Ph.D.; Administrative Director, Alliance for Clinical Education.