Words as Windows: Using Language to Move Toward an Inclusive Environment

In health care, language simultaneously has the potential to liberate and leave out. The words we choose to use or not use shape our institutional environments and identities. When considering the language of diversity, equity, and inclusion (DEI), it can be challenging to understand and endorse concepts that are constantly evolving. For example, it is becoming more common to share pronouns during introductions and use phrases such as stereotype threat, code switching, tone policing, minority tax, and emotional labor. Language signals our values, communicates norms, and creates feelings of exclusion or inclusion.¹  In short, language drives culture. The challenge is how to examine the language we use in our programs, to create a more inclusive climate.

Language influences learners' feelings of belonging, resilience, identity, self-efficacy, and achievement.²  Consider the amplification cascade. While certain individuals gain from the accumulation of privilege, others may find barriers compounded by words used in successive narrative assessments, letters of recommendations, and Clinical Competency Committees (CCCs), each negatively building on the prior assessment.³  Language use is also affected by the shift to virtual meetings, which may sacrifice the rich language of gestures and facial expressions.

Language is dynamic: meaning and structure constantly shift within and across communities. When language understanding is not shared, we can alienate learners, patients, and colleagues. Consider a physician who refers to a patient as “he” or “she” when the patient identifies as “they”—this misgendering can shut down the working alliance and set a tone of exclusion. Examining word use can lead to changes in all program activities, from orientations to CCCs. Through a process of learning and reflection, we can consciously adopt words, adapt ideas, and alter our language to enhance the learning environment.

Understanding of DEI language issues will be based on our unique contexts and experiences. Concurrently, we must develop a shared understanding and vision of what terms and concepts mean within the varied settings of academic medicine.

1. Invite reflection. How do you address residents and faculty? First names, titles—does it differ? What are your blind spots regarding the language of DEI? If the terms used in italics in this Rip Out are not familiar, look them up. DEI work requires cycles of self-assessment and self-reflection before action. Taking time to explore one's own missteps and misuses of language will lead to internal change and self-awareness and lay a foundation for program planning and development.

2. Be mindful of the role of the marginalized. Consider what constitutes truly inclusive environments for those who have been historically othered. Representation matters, yet we cannot expect those who are minoritized to bear the burden of changing the structures producing their marginalization.

3. Connect with others who want to explore language. Tell staff, residents, and faculty what you are reading. Share your reflections. Invite those with power and privilege to join you. Observe the language used in everyday work: journal club, annual program evaluation, and curriculum committee meetings. Examine how different stakeholders use language. Who talks first? Who is given license to interrupt? Who isn't? Are equity issues raised? When raised, are they discussed or dismissed?

4. Gather DEI stories from the literature. Investigate individual experiences with equity and inclusion. Share articles from your specialty and medical education journals to examine different facets of DEI.

1. Use existing structures and daily work to develop interventions. Add a standing DEI agenda item, focused on DEI terms and concepts, to all recurring meetings for discussion. Evaluate the words used in handbooks and in written policies. Over time, this enhanced understanding of language can be included throughout the program, in clinical experiences, and in curriculum, grand rounds, journal club, and morning report.

2. Listen actively to create room for narrative. Once most program members have done their individual work and existing forums incorporate DEI discussions, create safe, confidential spaces to hear what people in your program have experienced—and are experiencing. Consider asking someone outside the program to seek feedback from students and residents, to ensure safety and confidentiality. Use lessons from these stories to better understand how DEI concepts operate in your residency program and potential areas for change.

3. Create tools to sustain language change. After identifying areas of need, identify structures and belonging cues to sustain accomplishments. Develop a shared database of resources (eg, articles, websites, MedEdPORTAL modules, toolkits) and modify physical and virtual workspaces to reflect open, welcoming environments (eg, gender-inclusive signage in clinical spaces). Revisit your tools regularly, as language is dynamic, and residents change each year.

4. Look for the effects of language change. Keep listening in meetings to hear how people talk: who speaks (frequency, quantity) and who appears to garner respect. Use belonging scales like the Diversity Engagement Survey,⁴  along with annual surveys, to look for surrogates of inclusivity such as faculty professionalism. Transcribe meetings or gather written reflections; utilize software like Linguistic Inquiry and Word Count⁵  or word clouds to quantify how language is used, such as the most frequent or dominant words used.