Responding to Feedback around EDI Topics

Laying the Groundwork

Giving and receiving feedback between instructors and learners can often be akin to a missed high-five. The goal of this module is to introduce the fundamental framework for the rest of the resource. Building on that, we want to acknowledge the validity of common reactions to feedback and introduce a different lens (label vs. state) through which these can be interpreted and acted upon. 

Fundamental Framework: Competence vs Humility

The prevailing theory underlying anti-racism and patient-centred training in medicine has been cultural competence. The foundational assumption here is that there is something someone ought to know and a threshold to clear. Cultural humility on the other hand is a framework that acknowledges that physicians, teachers, and learners are on a continuous arc of learning and should be open to questioning and learning as they serve specific populations. The competence framework has been successful because it fits into various other areas of medicine where there is thresholding to establish competence, but this is also what makes it counterproductive. An effect of this model is that it penalizes and "calls out" rather than "calling in"; it also triggers a natural and common defence mechanism in those who are getting difficult feedback because the underlying assumption is that of cultural incompetence. Furthermore, many report feelings of guilt and shame when being called out or in. Identifying triggers can allow us to step back and evaluate feedback more objectively, rather than as a personal attack and more effectively work through the potentially negative emotions elicited by feedback. 

Why is identifying triggers important? 

Common triggers to EDI-related feedback (Cornes et al., 2022):

1. Identity triggers: feedback is discordant with how one sees themselves.

2. Relationship triggers: lack of trust in the relationship or perception of the intention/motivation behind the feedback.

Triggers can result in counter-productive thought patterns that often dismiss feedback and create an "us and them" relationship between the feedback giver and the receiver. 

Label vs. State

A common example includes perceptions around "racism" as a label versus a state. Ibram X. Kendi beautifully outlines this idea in How to be an Anti-racist. Kendi describes a phenomenon where we treat racism as a label, leading us to relate it to examples where people have been explicitly and often violently anti-Black or anti-Indigenous. Since our actions, which are often implicit, do not match how we relate the idea of racism with historical/modern examples, we falsely conclude that we are not racist. The reality is that we are at any point in our lives actively acting to be either racist or anti-racist as a transient state. 

Under this model, good people can be racist too. This is not a commentary on their individual moral character but rather a movable slider along a spectrum of actions. The goal is not to be infallible, it is to adjust in the face of feedback to be more anti-racist at any one time. 

This point is easiest to make with the example of racism but can be applied generally to any "-ism." Systems can and do entrench implicit racism into structures, policies and cultures. But much like water to a fish, we all have a hard time identifying these systemic issues when we are unknowing participants. Feedback from peers, community members and learners can allow us to go from unknowingly contributing to actively dismantling these systems. Our moral minds are built to protect our self-image and reputation, so they often dismiss, minimize and antagonize information that is contrary to our self-perception. Identifying triggers of this in-built protection mechanism is one method of avoiding thought patterns that diminish our ability to grow. 

The Power of the Preamble

A preamble is essentially a way of framing a conversation to provide additional information about the thought process and assumptions that go into a statement. 

Goals of a Preamble

Although these can be the intent behind a preamble, they are not necessarily all applicable simultaneously.

• Provides critical context to help the audience frame and interpret the incoming information

• Creates an environment where people are comfortable making and learning from mistakes

• Humanizes the instructor and establishes them as a lifelong learner 

• Aids learners in understanding the instructor's clinical decision-making and use of evidence (for the purpose of emulation)

Sample Preamble

Statement: The South Asian population is at higher risk of cardiovascular disease.

Potential Learner Feedback: The South Asian population is not a monolith; what specific subpopulations within the South Asian community are you referring to, and what are the potential reasons for their higher risk?

A preamble could have addressed feedback concerns and prevented the feedback in the first place.

Preamble: Epidemiological data provided today is (1) limited by the population groups chosen by the literature, and (2) limited in its resolution of smaller subgroups, as it has to balance clinical significance with data specificity to allow us to make actionable assertions about population risk. It may be warranted to advocate for more granular population subgrouping in research in the future. Appreciate that these are assertions about population risk, and learners should be aware of letting relative risk skew their broad differentials when met with an individual. 

A preamble can set the foundation for the information to be shared. These can be followed up by additional context that can enriching. 

Additional context: Studies that do look at more granular subgroups of South Asian populations find that their subgroups individually and independently have higher cardiovascular risk compared to other populations in Europe, Asia, and the Americas. Therefore, regardless of how granular we get, the statement about the higher risk of CVD in the South Asian population holds true.

References

• Cornes, S., Torre, D., Fulton, T. B., Oza, S., Teherani, A. & Chen, H. C. (2022). When students’ words hurt: 12 tips for helping faculty receive and respond constructively to student evaluations of teaching. Medical Education Online, 28(1), 2154768. https://doi.org/10.1080/10872981.2022.2154768