Trainee Experience With Racial Affinity Caucusing

In 2003, the Institute of Medicine published Unequal Treatment, the landmark report that catalyzed conversations about health disparities and the need for system change.¹ Further research stressed the impacts of racism in academic medicine. Yet the Accreditation Council for Graduate Medical Education (ACGME) did not mandate diversity, equity, and inclusion (DEI) efforts in all residencies until 2020. A lack of evidence on DEI policies and interventions in graduate medical education (GME) has left programs struggling with these requirements.

One intervention, racial affinity caucusing (RAC), invites individuals to separate into self-identified racial groups (eg, Black, Indigenous, or People of Color [BIPOC] or White groups). For White participants, RAC focuses on addressing white privilege and internalized supremacy; in BIPOC RAC, participants engage in deconstructing internalized racism and exploring interracial dynamics.²

RAC can be traced to social movements and theories of change that emphasize the need for spaces that foster shared learning and healing and is increasingly recognized as a critical component of antiracism curricula in education. We modified the framework of the Crossroads antiracism theory of change (Figure 1) to illustrate RAC’s potential role in dismantling institutional and cultural racism.^2–4

Currently, no known published studies on the experience of RAC for trainees (residents/fellows) exist. The goal of this study was to identify trainee motivations, benefits, and possible unintended harms related to RAC participation in order to contribute to the development of evidence-based DEI practices in GME.

This exploratory qualitative study used a constructivist paradigm.⁵ Trainee participants’ experiences were sought using semistructured interviews. We then applied a directed content analysis approach to interview transcripts to discern patterns across participants’ experiences.

Housed at the University of Washington, the Family Medicine Residency Network (FMRN) comprises 33 family medicine residencies and 10 rural training programs across Washington, Wyoming, Alaska, Montana, and Idaho. From September 2021 to March 2022, four RACs were offered virtually to all 733 FMRN trainees. A total of 30 participants over the 4 sessions included 19 BIPOC and 11 White, with an average of 11 per session. Thirteen attended more than one session (Table 1).

RAC sessions were facilitated by FMRN program faculty, some experienced facilitators, and others in training. Facilitators in-training were paired with experienced facilitators to co-lead sessions. Cofacilitators collaborated in advance of each session to select session topics and determine any needed materials or presentations.

A semistructured interview guide was developed to explore (a) motivations, (b) benefits, and (c) unintended harms caused by RAC participation.

In April 2022, audio-recorded Zoom (Zoom Communications, Inc) interviews were conducted with trainee participants, lasting 18 to 29 minutes. To promote trust, BIPOC participants had a BIPOC interviewer, White participants had a White interviewer, and interviewers were not part of the interviewee’s residency program. Transcripts were cleaned and deidentified.

Transcripts were analyzed using Dedoose version 9.0.62 (SocioCultural Research Consultants LLC). The team developed a start list of codes representative of study aims and constructs of the modified theory of change noted earlier.⁶ The start list was applied to a subset of interviews, refined, and finalized. Each interview was independently coded by two team members. Intercoder reliability was assessed subjectively. Discrepancies were resolved during study team meetings. The study was determined exempt from institutional review board review by the University of Washington Human Subjects Division.

Out of the 30 trainee participants, 8 (7 BIPOC, 1 White) participated in interviews. Table 2 highlights the themes raised with exemplary quotes. All interviewees expressed several of the themes:

• Safe space: “a place to express their kind of intimate and vulnerable emotions around white supremacy” –White participant

• Self-reflection: “the experience has taught me not to keep doubting myself when I have interactions that didn’t feel right, or I know [were] wrong.” –BIPOC participant

• Behavior change: “There are certain things that . . . RAC has taught me, like macroaggressions and microaggressions. Being able to call it out in front of an aggressor. That has been something . . . RAC has empowered me to do.” –BIPOC participant #1

The themes primarily were centered around the trainee experience of RAC and were tied to the short-term outcomes in the theory of change model.

Beyond the short-term outcomes, some discussed how their RAC experience would impact their patient care. A White participant said, “[RAC] is not for yourself. It is a necessity . . . if you want to be a provider for someone who is of a different race.” A BIPOC participant reflected, “[RAC] is a good way to . . . hear about [the] trauma of racism to help get a better perspective, especially as someone who is going to be a doctor taking care of humans from all different backgrounds.”

The themes (Table 2) from this pilot study aligned with our hypothesized short-term outcomes for trainees in our framework (Figure 1), such as safe space, self-reflection, and concept of race/racism. This outcome aligns with existing literature⁷ and suggests that RAC may have similar benefits in GME. We observed themes around behavior change, which could be an indication of movement toward intermediate-term RAC outcomes (Figure 1). Specifically, participants reported that RAC gave them language and empowerment, like how to “call out acts of racism to my peers, to my faculty, to the people around me” (BIPOC participant). This finding aligns with other reported experiences as well.⁸ We expected to hear more about the link to larger institutions, but that was rarely mentioned during interviews except in the context of RAC changing a trainee’s approach to patient care and self-reflection, possibly because our study spanned only 1 year. If RAC is implemented for longer, the impact could be amplified; a previous study with family medicine faculty indicated that increased exposure can improve the perception of RAC.⁹

Our sample was subject to response bias; RAC participation was self-selected, and participants may not represent the general trainee population. In particular, we were not able to reach theoretical saturation in our analysis for the White participants; this is consistent with the lower participation from White trainees. We hypothesize that White trainees who may not have experience examining their own race are more likely to be intimidated by RAC and have less perception of the potential benefit. Further studies could explore how to engage White audiences more effectively.

Our findings underscore the potential of RAC not only for advancing antiracism efforts at an institutional level, but also for the well-being of BIPOC trainees. RAC provides a crucial space for psychological safety and community building, which are vital for the personal and professional development of BIPOC individuals. Given the novel context of multi-institutional RAC in a GME training setting, we believe that our findings build on a theoretical framework for RAC in GME and leave space for future studies.