A Qualitative Study of Residency Faculty Motivations, Skills, and Preparedness to Facilitate Racial Affinity Caucusing

Racial affinity caucusing (RAC) is increasingly recognized as a powerful tool to address the needs of Black, Indigenous, and people of color (BIPOC) medical residents and as a key component of anti-racist and diversity, equity, and inclusion (DEI) curricula.¹  Despite growing attention to the need, including the Accreditation Council for Graduate Medical Education’s (ACGME’s) 2020 requirement for all residency programs to address and report their efforts in DEI,²  many residency programs struggle with implementation. As evidence, a 2020 survey from the Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity Committee indicated 50% of family medicine program directors lacked confidence in implementing the common program requirement change pertaining to diversity.³  Similarly, internal medicine program directors indicated concerns related to their limited scope of influence and lack of institutional commitment.⁴ 

RAC offers structured spaces where individuals, grouped by racial identity, can engage in discussions that address racism and white supremacy.^1,5  It has been implemented across academic and community settings to foster environments of healing and belonging, especially for BIPOC individuals.^5-7  RAC creates opportunities for participants to reflect on their identities and contributions to institutional racism, making it an important tool in addressing disparities in medical education and clinical practice.^1,5,8 

To understand how RAC facilitator training and subsequent RAC sessions may contribute to creating an anti-racist culture in medicine, we generated a logic model (Figure). The faculty training part of the logic model, which this project addresses, was designed to map against principles of social cognitive theory (SCT) to explain the possible relationship between training and preparedness to facilitate successful RAC. SCT posits that learning occurs in a social context and that subsequent behaviors (ie, successful RAC facilitation) are a result of dynamic interplay of individual experiences, interpersonal interactions, and the environment.⁹  The theory describes 6 constructs that influence the process of learning: (1) reciprocal determinism: the interaction of an individual, environment, and behavior; (2) behavioral capability: having the skill to perform a behavior; (3) observational learning: observing outcomes of others modeling the behavior; (4) reinforcements: responses to a person’s behavior that affect the likelihood of continuing that behavior; (5) expectations: determining outcomes of behavior change; and (6) self-efficacy¹⁰ : belief that an individual can successfully perform a behavior.¹¹ 

The need for addressing racism and including DEI curricula in residency training is well-established, and RAC implementation may meet this need.^12-15  Few, if any, theory-based curricula or tools exist to prepare medical educators to facilitate RAC.⁸  The perspectives and experiences of faculty who have been trained to do so may be particularly valuable for designing effective training programs that build capacity to dismantle racism in medicine.⁶ 

This study aims to understand how RAC facilitator training influences faculty readiness to implement RAC, with an emphasis on motivations and key skills and resources necessary for successful facilitation.

In this exploratory qualitative study, we utilized a constructivist paradigm to put emphasis on the participants’ own lived experiences,¹¹  in which an understanding of RAC facilitators’ individual experiences and perceptions were sought using semistructured interviews. We then applied a directed content analysis approach¹⁶  to interview transcripts to discern patterns across facilitators’ experiences. An established Crossroads’ theory of change posits that, “antiracist transformation of institutions and systems can begin through understanding how they participate in and are integral to white supremacy, and providing spaces of reflection for individuals to interrupt behaviors that sustain white supremacy culture.”⁶  Building on this theory, we integrated SCT constructs with lived experiences of residency faculty to identify and describe the faculty’s motivation to participate in RAC facilitator training, as well as the skills and resources they perceive are necessary to facilitate RAC.

Housed at the University of Washington, the Family Medicine Residency Network (FMRN) comprises 32 family medicine residency programs and 10 rural training programs across the 5-state region of Washington, Wyoming, Alaska, Montana, and Idaho. In June 2021, all FMRN program directors were invited to nominate faculty to participate in RAC facilitator training. Twelve faculty were nominated, and all were accepted to participate in the training. The faculty included 7 (58%) BIPOC and 5 (42%) White. Nine (75%) were MDs and 3 (25%) PhDs. Their level of experience ranged from 4 to 10 years as residency faculty with an average of 6 years. Seven (58%) were trained in the Northwest, 2 (17%) in the West, 1 (12%) in the Midwest, and 1 (12%) in the Northeast. A brief overview of our RAC facilitator training is provided in Table 1. Faculty participants attended 20 hours of training spanning 6 months (September 2021 to March 2022). Part of the training included co-facilitating RAC sessions for regional residents with experienced facilitators. After completing training and facilitation of these RAC sessions, all faculty participants were invited to participate in a brief semistructured interview. Interviews took place March through May 2022. The study team members (M.O., A.W., P.E., T.H., G.S.) received formal training from an experienced qualitative researcher (S.D.H.) and then together developed a semistructured interview guide (provided as online supplementary data) with input from S.D.H. The final guide included 11 questions and probes that aimed to identify (1) motivations for RAC facilitation, (2) skills that faculty facilitators perceived as important to successful facilitation of RAC among residents, and (3) faculty preparedness and ability to implement RAC within their own institutions. The study team cross-walked interview questions and code categories with SCT constructs to help ensure that interview findings could inform theory-guided learning interventions in the future.¹⁷ 

Three team members (T.H., M.O., G.S.) conducted audio-recorded interviews with faculty participants via Zoom, which generated transcripts for each interview. Interviews ranged from 13 to 44 minutes in length, with an average of 20 minutes. To promote trust and safety, BIPOC team members (T.H., G.S.) conducted interviews with BIPOC faculty and a White team member (M.O.) conducted interviews with White faculty participants. M.O. and T.H. subsequently cleaned and deidentified transcripts.

Transcripts were entered into Dedoose qualitative data management and analysis software version 9.0.62 (SocioCultural Research Consultants LLC). The study team developed a start list of deductive codes representative of study aims and inductive codes representing constructs of SCT. The start list was applied to a subset of interviews; additional codes were added as appropriate and refined. Through an iterative process, codes were grouped under higher order headings representative of the study aims,¹⁸  and a final codebook was agreed upon by all team members. Each interview was independently coded by 2 members of the team using the final codebook (provided as online supplementary data); coders were blinded to others’ codes. Intercoder reliability was evaluated subjectively. Discrepancies were discussed and resolved during study team meetings.

The study team included 2 family physicians (G.S., P.E.), a public health researcher (A.W.), 2 staff members (T.H., M.O.), and a mixed methods researcher (S.D.H.). Study team members represented diverse educational backgrounds and varied racial and ethnic identities. The intersectional identities of team members aimed to ensure that multiple interpretations of the data were considered, that credibility was promoted throughout study phases, and that perspectives described by participants were authentically reported.¹⁹ 

The study was determined to be exempt from institutional review board review by the University of Washington Human Subjects Division.

All 12 faculty participants were interviewed. We organized 15 identified codes and corresponding quotes into 2 overarching categories representative of the study aims (Table 2): (1) motivations for and perceived benefits of obtaining RAC facilitator training, and (2) critical skills for successful RAC facilitation. Representative quotes were chosen for their succinct characterization of corresponding theoretical constructs. Within each of the higher-order headings, we included codes and corresponding illustrative quotes and constructs of the SCT. Quotes represent a range of participants, but to maintain confidentiality of this small sample, participants were identified by their racial group (BIPOC or White) only. The final column lists corresponding SCT constructs to situate our findings in the context of SCT constructs that appeared to influence RAC facilitator learning.

The dynamic interplay between individual faculty participants and their residency program environment (reciprocal determinism) was a core driver of participation in RAC training. All but one respondent indicated that they were motivated to learn RAC facilitation because they saw a need for anti-racism training in their program. Participants also expressed that the individual expectation of personal growth was a key motivating factor.

While the concept of creating a “safe space” was both a motivator and a benefit noted across both groups of faculty, BIPOC and White faculty described nuanced differences in how RAC was a unique space. BIPOC faculty described RAC as “one of the only places that you can build community…you talk about those specific things that affect BIPOC folks in training like imposter syndrome and code switching, and that sort of thing which we don’t talk about as a residency, which is really important piece of healing trauma” (BIPOC faculty #1). In contrast, White faculty noted the RAC space as one where they could discuss institutional racism without burdening BIPOC colleagues. One White faculty stated, “I really believe that White caucusing creates space for addressing institutionalized racism…without putting that burden on Black and Indigenous [people]” (White faculty #1). Several White faculty also referenced RAC as a space where people could feel discomfort together with one faculty saying, “Where else are you going to be challenged to reflect on what it means to be White and to be White in a racist world?…There’s something really valuable… to sit with some of the discomfort and be able to be supported by other White folks, and doing that uncomfortable work. I don’t think that there’s any spaces that are really comparable” (White faculty #1).

Observational learning/modeling was identified as playing a central role in the faculty training, with all participants recognizing key elements, such as facilitation practice, debrief sessions, or modeling their own learning, as critical to their facilitation skillset. In particular, all faculty identified RAC facilitation practice as being a key component of training, stating that “the real learning was actually the practice” (BIPOC faculty #1). Most faculty also shared the importance of modeling the learning process, with one faculty explaining “I don’t have to get it right and in fact, not getting it right is maybe even a great opportunity to just sort of model, some of that [is] what RAC is supposed to be about” (BIPOC faculty #2).

The majority of faculty, especially BIPOC faculty, also identified that having skills to manage their own emotions was critical in RAC facilitation. One BIPOC faculty described “learning how to handle your own emotions…even things that could come up for yourself as part of a trauma response” (BIPOC faculty #6) as an important skill. A White faculty described learning that “when posing questions, discussion, questions to the group, [it] really started with some self-disclosure. And answering the questions for myself in a way models for the group. Reflecting on my own stuff, watching my own whiteness to my privilege” (White faculty #1).

Several faculty, mostly White, identified that acquiring foundational knowledge of race and racism was important, and that understanding the “why” of RAC and receiving training on general facilitation skills were core foundational knowledge and skills gained from the training. They also identified other skills desired that were not covered in our training, such as mindfulness, conflict management, how to run group therapy, and differences between facilitating in-person and virtual RACs.

Faculty described a variety of factors influencing whether they could facilitate RAC in the future, including those over which they had individual control (self-efficacy) and those at the interpersonal, institutional, and community levels (reciprocal determinism and reinforcement). All respondents mentioned the importance of interpersonal influences, like co-facilitators, for conflict management during a RAC session and as personal support; several participants also expressed a desire for a support network among RAC facilitators or ongoing resources through FMRN. Many participants emphasized that crucial structural factors—such as institutional and leadership buy-in and support, protected time, and money—influenced their ability to implement RAC. These are summarized in Table 3.

Our findings suggest that a brief, 20-hour training program for RAC facilitation may be sufficient for physician faculty, given that many of the core facilitation skills overlap with existing clinical competencies such as counseling and small group facilitation. However, certain skills, such as managing emotions during discussions and understanding anti-racism concepts like microaggressions, implicit bias, privilege, and White fragility, were unique to RAC facilitation and may require additional focus in future training sessions.

For organizations looking to get started, we identified several key structural factors for implementing RAC (Tables 2 and 3); these findings expand on what has been suggested in previous literature, specifically offering RACs in conjunction with other anti-racism curricula and needing explicit support from program leadership and involvement of leadership and learners from the start of the process.¹  In our study, participants identified the importance of leadership support and highlighted the importance of understanding their institution’s motivation and goals for implementing RAC. Participants also reported the importance of a co-facilitator within their same racial affinity group as well as having the facilitator capacity to run both a BIPOC and White RAC. Having co-facilitators helps provide psychological safety for a successful RAC and distributes the emotional labor of facilitation among several people.

We found that our faculty described nuances in training needs for BIPOC and White facilitators, which aligns with the different needs and experiences of BIPOC and White RAC participants and trainees.^1,12  Specifically, BIPOC faculty emphasized the need to have skills to simultaneously recognize and manage their own racial trauma during facilitation, while White faculty shared more desire for training on foundational racism/anti-racism concepts. We hypothesize that these differences in facilitator training needs exist because of the different experiences and goals for RAC for White and BIPOC groups.⁶  As described by Just Lead Washington, BIPOC RAC “is a place to work with their peers on their experiences of internalized racism, for healing and to work on liberation.”⁵  For White people, “a caucus provides time and space to work explicitly and intentionally on understanding white culture and white privilege and to increase one’s critical analysis around these concepts.”⁵  As noted in our logic model (Figure), the impact of faculty facilitator training is different for BIPOC and White participants. As such, future training sessions should be tailored to the different needs of BIPOC and White facilitators.

Our study has several limitations. First, all training and caucusing were conducted virtually. This was necessary because our faculty participants were located at 8 different residency programs in 2 states with caucusing open to participants in 5 states. While this geographic diversity represents a strength of the study, it is possible that different skills are needed to facilitate RAC virtually compared to in-person. In our study, faculty noted the importance of having co-facilitators who had the ability to text and chat with each other directly to discuss concerns during the RAC. This would be more difficult in an in-person session. Second, in our observation, RAC is often performed within one residency program or organization rather than among many residency programs or organizations. If conducted within one program, caucus participants are likely to have already established relationships and rapport with one another.

Future research is needed to explore the experiences of residents participating in RAC and to investigate if caucuses in which participants are largely unknown to one another have significantly different discussions, conflicts, or outcomes compared to caucuses in which participants have pre-formed relationships. Though the regional and virtual nature of our project may limit the generalizability of our study findings, it provides an example by which programs can collaborate with one another to provide RAC. Our program was developed, in part, because several individual residency programs did not have any or a significant number of BIPOC residents/faculty to form a caucus. Although ideally, faculty and residents in residency programs would equally represent the diversity of the United States, creating environments that actively foster anti-racism and support inclusion and belonging represents an early step toward achieving that representation. In the meantime, working collaboratively with other programs may increase the number of BIPOC residents/faculty that can caucus together.

This study uncovered faculty motivations for participating in the training and identified essential skills and resources necessary for successful RAC facilitation. Key skills included effective small group facilitation, emotional regulation during discussions, a solid understanding of anti-racism principles, and the importance of both practice and post-session debriefing.

The authors would like to thank Jessica Guh, MD, and Patricia Egwuatu, DO, for their contributions to this project. Drs Guh and Egwuatu helped design the format and content of the facilitator training. In addition, Dr Guh’s previous work on racial affinity caucusing for family medicine faculty was foundational to the project.

The online supplementary data contains the interview guide and final code book used in the study, and a visual abstract.

Funding: A grant from the University of Washington Center for Leadership and Innovation in Medical Education was received to help fund this project.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented as a poster at the University of Washington Department of Family Medicine Research Fair and Scholarship Forum, April 12, 2023, Seattle, Washington, USA, and as a Presentation at The American Academy of Family Physicians Residency Leadership Summit, March 25-27, 2024, Kansas City, Missouri, USA.