Building Inclusion and Belonging in Training Environments

The Accreditation Council for Graduate Medical Education (ACGME) requires that programs engage in practices that prioritize recruitment and retention of a diverse workforce.¹  To do so, graduate medical education (GME) programs must deliberately foster inclusive training environments with a genuine sense of belonging for all trainees, particularly those holding identities historically excluded from medicine. Yet creating these inclusive environments is fraught with challenges at the individual, interpersonal, and structural levels that interact in complex and often imperceptible ways.

The dominant GME climate is the clinical learning environment (CLE), a microcosm where learning and patient care occur in tandem. These professional settings are variably welcoming to learners due to institutional culture, structures, spaces, and social interactions.²  When learners are excluded, harassed, or subjected to bias and discrimination in the CLE, overall well-being suffers, which can produce depression, burnout, and attrition.² 

Many institutions and programs aim to cultivate inclusive environments, yet the paradigm of inclusion typically assumes the subjugation of identities to adapt to a static medical culture designed by individuals with historical privilege and power. Underrepresented in medicine (UIM) residents describe being perceived as “other” in CLEs and must downplay core elements of their authentic selves to survive.^3,4  Daily instances of micro- and macroaggressions, discrimination, bias, and racism³  negatively affect trainees' learning, ability to provide high-quality patient care, and well-being. Deliberately cultivating an environment of belonging in which everyone's authentic selves are valued, respected, and celebrated is imperative to ensure trainee success.⁵ 

1. Commit to diversity, equity, inclusion, and belonging (DEIB). Explicitly incorporate DEIB in all mission and values statements. The intentional formulation and expression of these values is a necessary foundation for DEIB efforts. Central to this commitment is understanding and acknowledging the legacy of discrimination and racism in institutions, medicine, and medical education.⁶  Value DEIB work equivalent to that of other traditional academic achievements in annual reviews, academic promotion, and leadership recognitions and advancements.

2. Collect and make transparent CLE climate data. Go beyond impersonal annual program and institutional climate evaluations to include data gathered through discussions led by trained external facilitators. Topics to explore include episodes of overt racism, bias, and mistreatment. Discuss positive experiences in which trainees felt seen or like they belonged, to define best practices to retain and share with others. Timely dissemination of this data is imperative. Organize open forums to present these findings and give trainees space to react, respond, and actively participate in conceptualizing solutions. Climate data must be publicly available and regularly updated to maintain transparency.

3. Act as personal navigators. Aggressively coach, mentor, and sponsor UIM trainees in all clinical and scholarly activities to counteract their historical exclusion. When conducting scholarly work, review the authorship block. Does it reflect your commitment to authorship diversity and promote skills acquisition? Clinical mentors should intentionally seek out UIM mentees. All mentors must initiate regular check-ins with their mentees to define goals, develop individual development plans, ensure follow through, and actively connect mentees with scholars within and outside the institution. Coaches should be advocates for their trainees while providing realistic and actionable feedback. Track and make these navigator metrics public.

4. Create safe and open spaces for dialogue to move from inclusion toward belonging. GME leaders must foster opportunities for trainees to reflect on their own backgrounds, intersectional identities, and authentic selves, and to celebrate their successes. These spaces should include regular opportunities for trainee identity affinity groups to meet off campus. Programs with few UIM trainees should partner to provide this space. These trainee-led conversations must allow sharing of experiences and opportunities to forge relationships. Faculty should attend only upon request. Institutions must be accountable for accepting, synthesizing, and responding to feedback provided by trainee affinity groups on a regular basis.

5. Build budgets that value and prioritize this work. Prospectively build support for DEIB efforts into all budgets and avoid segregating this work to a limited pool of financial support. Include funding for trainee attendance at regional and national conferences related to DEIB, off-campus social and professional events for trainees, and faculty training. Compensate DEIB leaders monetarily and provide protected time to mitigate the minority tax for those who engage in this work. Budget for external DEIB consultants to offer recommendations on accountability and existing initiatives.

1. Define and implement DEIB competency milestones. Create new competency domains and integrate these measures into existing assessments for trainees and faculty. Highlight understanding and practice of health equity, anti-racism, and anti-oppression. Define specific DEIB competencies for faculty in their roles as educators, teachers, mentors, and advisors. Include these competencies in faculty assessments.

2. Implement practical DEIB training for all faculty. Include CLE-specific DEIB skills and values in hands-on faculty development sessions. Provide opportunities to practice, receive feedback, and debrief. Familiarize faculty with literature on bias commonly seen in performance assessments and the effects of stereotype threat, imposter syndrome, tokenism, and homophily on trainee performance and sense of belonging. Teach faculty members how to respond to bias and misconduct from patients and colleagues. Use incentives to protect faculty time for training and require a basic, sustained level of competence.

3. Create a longitudinal equity, anti-racism, and anti-oppression curriculum for trainees. Center these issues in GME training programs. Recognize that lack of awareness of and action to oppose oppressive forces will perpetuate isolation and lack of belonging in UIM trainees.

4. Hold yourself and your program accountable. Ensure sustainable methods of data analysis and robust action plans to course-correct when necessary. Build reporting elements into the annual program evaluation and sponsoring institution's evaluation reports. Create a standing agenda item to present these findings at GME meetings and resident forums to identify gaps. Ensure action plans have accountability timelines and metrics. Implement transparent improvement plans for programs that are not reaching target benchmarks and assign leaders who perform well to coach lower-performing programs. Invest in periodic external program audits to provide unbiased feedback about current status and future directions.