Rebuilding Medical Education with Peace, Hope, and Love

In this episode of CLIMEcast, CLIME Associate Director Kate Mulligan moderates a live Conversation Café with CLIME leaders Addie McClintock and Justin Bullock, exploring their Academic Medicine paper “Our House Won’t Rebuild Itself: Peace, Love, and Hope as Tools to Transform Graduate Medical Education.”

Drawing on scholarship, lived experience, and audience dialogue, the conversation examines how graduate medical education systems can unintentionally perpetuate harm through pain, silence, and despair—particularly for trainees experiencing identity-based harms. Drs. McClintock and Bullock discuss the house metaphor at the heart of the paper, unpacking how bias, assessment practices, professionalism norms, and power structures shape learning environments.

The episode also focuses on pathways forward. Together, the speakers explore how peace, love, and hope can serve as practical tools for rebuilding learning environments while we are still living in them—emphasizing psychological safety, identity safety, belonging, and growth-oriented assessment. Audience questions deepen the discussion, addressing faculty wellbeing, institutional accountability, and realistic strategies for everyday clinical teaching. The result is a thoughtful, candid exploration of what transformative change in medical education can look like, at both the individual and structural levels.

Transcript

Amanda Garza: Welcome to CLIMECast. This episode was recorded during a live conversation cafe featuring associate directors of CLIME Drs. Addie McClintock, Justin Bullock and Kate Mulligan. Discussing Addie and Justin's Academic Medicine paper, “Our House won't Rebuild Itself Peace, Love, and Hope as tools to transform graduate medical education.

This paper was co-authored by Dr. Bullock, Dr. McClintock, Dr. Ryan Abe, Dr. Marcus Boos and Dr. Jennifer Best, and reflects a deeply collaborative effort to examine how graduate medical education systems can unintentionally cause harm, and how we might begin rebuilding learning environments grounded in psychological safety, identity, safety, and belonging.

This episode also includes questions and reflection from audience members as part of this conversation. We're glad you're here. Enjoy the episode!

[00:00:54] Kate Mulligan: Welcome, welcome, welcome to Dr. Bullock, Justin, and Dr. McClintock, Addie. Many of us know you both as key members of the CLIME Leadership team. Addie, you direct the Teaching Scholars Program and are an Associate Professor of Medicine in the Division of General Internal Medicine and Justin you are a newbie Assistant Professor in Nephrology and the Medical Education Scholarship guru for CLIME.

I could do a whole podcast about each of you and maybe we will in the future, but today I really wanted to highlight the paper. That you published in academic medicine at the end of last year. I really wanted to try and amplify that. The paper was called Our House Won't Rebuild Itself, Peace, Love, and Hope as Tools to Transform Graduate Medical Education.

And it truly just blew me away. It sort of challenges the status quo and invites us to deeply examine the structural and cultural dimensions that shape how our medical trainees experience learning, identity and belonging in our systems. For many of us in medical education, the work is really inspiring and challenging because it asks us to look inward at, at ourselves as teachers and also outward at the systems that we're really perpetuating, uh, unintentionally I hope for the most part today, we hope to explore how faculty can meaningfully contribute to building a safer, more authentic learning environment, especially for medical trainees.

But it probably goes for all health sciences trainees. So welcome and welcome to everybody who's here. My first question to my wonderful guests has to be like, what was the impetus for the paper? Like, why this paper? And why now? 

Justin Bullock: Thank you very much for having us. We're both very excited to be with you all.

So happy to start off by acknowledging our amazing team. So in addition to me and Addie, Dr. Jennifer Best, Dr. Ryan Abe, and Dr. Marcus Boos. Jennifer was sort of the glue that brought us all together. She was recently a Macy Scholar, which is a very kind of cool, very prestigious award from the Josiah Macy Junior Foundation.

They do a lot of philanthropic work, supporting medical education scholarship. They have these grants for innovation and graduate medical education, and a few years ago, their grant focused on promoting civility, safety and belonging in the learning environment. And because Dr. Best was one of the Macy scholars, , she was invited to build a team to write a piece that kind of served as a summary piece looking across, the numerous different innovations that had been sort supported by the Macy Foundation.

And that's kind of how our team first came together to an, I think the second part of your question, just one more comment of the why now. You know, as we got together, one of the funnest parts, at least for me of doing this work was, we just had a lot of really cool conversations. And I think as we all came together initially, we were like, let's burn the house down.

Like, you know, like, and pretty quickly we kind of got to this place where we're like, well, we are still in the house and so like if we burn the house down, we're gonna burn ourselves down too. And that kind of was sort of one of the jumping off points for as we were thinking about writing the piece.

Kate Mulligan: Great, thanks Justin. I will note that Jennifer Best was invited to come, but she had. Other commitments and she's here in spirit with us and looking forward to our podcast at the end. So thank you for that. In case some of you didn't get a chance to read the paper, we were gonna ask a few questions that illuminate parts of the paper.

I would strongly recommend reading it. But one thing, Addie and Justin, you use the metaphor of the house to describe graduate medical education, a house that. You say was built with pain, silence, and despair, and which impacts, especially those who suffer identity-based harms. Can you give us a few examples of how this harm manifests and elaborate on that a little bit for us?

Addie McClintock: Sure, yeah I think unfortunately there's kind of no shortage of examples in of what sort of what we were calling pain in the paper, and largely we were talking about some of the ways that people might experience emotional pain as trainees and one of the things we sort of talk about is how there are certainly things that impact all of our trainees.

Things like disruption of your social networks when you're working so much, or the fact that you might need to be totally removed from all your social networks to match somewhere where you don't know anybody in order to pursue the residency that you want. Other things like financial disruption can be difficult and challenging to deal with.

And then there are some things that are totally just unavoidable in medicine for everyone, including, things like clinical events that occur, things we witness as providers, um, in the lives of our patients or the people that we care for and care about. And also difficult patient events can occur, which are difficult, to name just a few, and then we did think a lot about wanting to highlight some of the things that really disproportionately impact trainees from specific groups. So some of the data that we talk about in the paper are, uh, data about stereotype threat. There is a lot of talk about how female physicians, for example, are often perceived to not be team leaders of their team during codes.

They may get feedback that they're too aggressive, too meek, for example. There's also quite a lot of data from surgery in particular where um, studies have been done, but certainly not the only place these things occur. In the New England Journal, there was. 7,400 surgical residents and 65% of women residents said that they had experienced gender discrimination and harassment in training.

There's also a paper, which I think is actually not in our talk, but I went to find the exact quote from their results and it's describes, the experiences of underrepresented trainees, and it says, the quote is a daily barrage of microaggressions and bias. Minority residents tasked as race and ethnicity ambassadors and challenges, negotiating professional and personal identity while being seen as others.

This also applies to those who trained outside of our country, often being sort of forced to acculturate to new norms, um, without resources to sort of support them in that. Then another way we talk about some of the pain that occurs in medical education is through assessment and the ways in which we know that there's quite a lot of bias in the way that we use number ratings to evaluate trainees and the ways the language that we use in narrative description.

And there is a lot of data that those tiny little things really can add up. So might impact your final grade because you didn't quite get honors, and then you aren't gonna be eligible for an OA, and then you might not match into the residency program you were hoping for. And it's just these tiny, tiny things develop into this very large cascade of events that can hugely impact the larger things of career opportunity, career advancement for people.

I'll turn it over to Justin. 

Justin Bullock: Thanks, after we talked about pain, then we moved into also talking about silence and despair, and for us, silence was representing the, like in the context of all these identity based harms, the very real sort of fear and repercussions that come from speaking up or speaking out and.

That our system is overall very effective at actually suppressing that, speaking out. One of the ways in which this is enacted is through. Weaponizing. Professionalism. Professionalism. I, I hold it in two ways. One, there is something there, I believe in essence, about what it means to be a physician, that we have certain values that are sort of largely accepted by our profession.

Um, and anytime you have a force that's attempting to describe a group, it can be very sort of confining and constraining and some of the things that sometimes when people's. Speak up. Um, what often has happened was they're placed with professionalism flags if they challenge supervisors or, or speak out in other ways.

And so through this silence is enacted or forced to occur. And then despair really refers to what happens in the context of having both pain and silence. There's data around physician suicide that resident physicians die at by suicide at three times the rate of their age match peers. And this is also in the context when they're in healthcare settings.

So theoretically have more access to healthcare than than many of their. Similar peers, but also just the substantial amount of attrition. The surgical literature is, is actually a, um, in this way I would say it's a very progressive space because I think compared to the other spaces, there's not as much written or talked about with attrition.

There have been some really kind of moving pieces, qualitative and quantitative data demonstrating, in particular for women surgical trainees, a lot of the different societal forces that that can influence attrition and. Basically despair is sad for me. It's a very sad thing. It shows that it is a sort of.

Physical representation of what happens when we aren't sufficiently supporting and caring and creating sort of identity safe or psychologically safe spaces. 

Kate Mulligan: Thank you, Justin and Addie. It's a little heavy to take all of those harms on, but I think we have to recognize what the issues are and what the problems are.

I don't. I think it's too early though, to maybe talk about the solutions. So your paper actually elaborates on solutions. Not to tear the house down, but to rebuild it with peace, love, and hope, focusing on creating psychological safety, identity, safety, and a sense of belonging. Can you elaborate a little bit more on this and how did those themes emerge when you're discussing how to, how to approach the paper and frame the way to go forward?

Addie McClintock: We, we definitely did have a lot of like, kind of rich and fun discussions, like Justin said, like, burn it all down. If you know me, that's kind of who I am. Um, maybe a little bit too early on the burn it down however we felt like. You know, initially it was sort of this idea of like, okay, if you have water in the basement of your home, it's not gonna do much if you repair the roof or the window, when in fact it's pouring in through the foundation.

And so thinking about it from that way, we also thought about the found there are some amazing foundations and some things worth saving. I know Kate's next question is like, what? And we talked a little bit about, um. One of the things that's so amazing is our educators and the people here on this call, those who might be listening to this podcast, and those that are busy right now, educating our trainees, but those are people who come to academic medicine with the love of education.

They get deep Sense of value and meaning from being our educators and being in that place of supporting trainees. And those are things we want to keep. We want to support our educators who support our programs and our trainees. Um, those are things worth recognizing as wanting to keep and stay. We also talked about our, our training programs.

Currently they are working, uh, to train physicians ready to practice independently, and that is also something we don't want to give up or compromise in change. The paper, the discussion today, all of that is very much about like, could we accomplish that in a different way? So I'm not sort of saying that we're doing it great now, but that is an end goal that everybody shares and thinking about what's the value behind, sort of like the value-based change we wanna make is sort of where we ultimately came from.

Kate Mulligan: Justin, did you wanna add it? 

Justin Bullock: Yeah, I just wanna squeeze one thing in, which is really just building on what Addie is saying is, you know, from very recently I've been lucky to get to work on a project with Jennifer Best and we are having the opportunity to interview program directors across multiple institutions.

And for me it's been really eye-opening to sort of. See the complexity of the role of program director, of how you're beholden to many different people and like how they're trying to like hold up the roof for their trainees in very complex situations. I've gone through training and had variable feelings about program director.

Some great, some less than great, but I think to see how. Tricky and challenging it is, I think is the thing that I am like most taking away from the opportunity that I've had to, to hear from program directors recently. 

Kate Mulligan: Okay. So we have a few good bones at least. What strategies or or tools emerged in your group, uh, that you.

Propose for trying to rebuild the house while we're still living in it, rebuilding the house around us. 

Addie McClintock: One idea that was really appealing to me, I was listening to a completely unrelated podcast about a ADHD of all things and I don't know why the speaker was on there, but he was talking about the power of hope to help people heal from trauma.

And he defined hope as the belief that the future will be better, that you have the power to make it so, and it's three main ideas. It's desirable goals, pathways to goal attainment and agency and willpower to pursue those pathways. And I felt like that's what we were really talking about in this paper, thinking, creating.

Hope through a, a new pathway of achieving a goal, and I just love that concept. I also thought, you know, in terms of healing and improving the environment, my own brain went to psychological safety, which in dis full disclosure is my area of scholarship and interest. So it was kind of a no-brainer. It's a hardwired circuit in my brain these days.

Most of the behaviors that create safety are effectively. Tools for creating connection and for power sharing. So that's kind of where the concept of love came from, this idea of connection and caring for one another. And because psychological safety is often considered kind of like an interpersonal construct, like it's created through your actions and your behaviors with others around you, it also feels like something like.

I today can affect change. There may be other things around you that can be difficult about that for sure, but the idea that just how I treat the person I'm interacting with right now today could affect some change was really appealing to me because big scale cultural change can be super difficult, but we can make choices in our everyday interactions to sort of create those moments that.

Bring engagement and belonging. Psychological safety brings sort of better access to your cognitive resources. Justin's probably gonna talk about this a little bit more, but just the idea of like, if you're so focused on worrying about everything around you, that's extremely distracting. We do not have infinite brain processing power, and so the more you can free up that content to let a person really focus on their learning and their.

Performance for, you know, optimal assessment. That's really something that we should strive for. And again, sort of like under comes from a shared value of wanting our trainees to have the opportunity to learn and grow. 

Justin Bullock: Addie hinted at this too, but one of the foundations of like us building this piece was as the team was built, we all have like things that we spend a lot of time thinking about.

You know, like Addie is international expert in psychological safety. You know, Jennifer studies belonging. I've recently been very interested in this topic of identity safety, and so while those concepts are for us, like shiny objects that we like, there was something impactful I think about. Not using like researchy terms, but like to sort of try to evoke the human emotions that we all experience on a daily basis.

You know, I'm biased, but I thought it was really cool. I really like that. And so one of the things I guess that, for instance, that I felt. Using Love could do. Instead of saying identity safety was, we talk about like there's different types of love and how love is like a very, it's not a very okay thing to talk about, you know, and say that you love your trainees or you love your patients or all these things and.

There's different types of love. So there's like aeros, which is like romantic love, which is not really what we're talking about. The con that we make in the paper is there's agape, which is like selfless love. Um, and then I'm probably pronouncing this wrong, I've only read it Thia, which is like self love and in medicine.

We very much support agape, like endlessly pouring out to other people, caring for patients, going the extra mile, like doing all these things. But we actually don't really prioritize or talk about like self-love and, and there are limitations to that. And so I think the first, just like playing with the concepts around these very normal feelings.

I found to be enlightening for myself. I'm not sure I've add, you said this already, but we also tried really hard to make these tables where we had specific recommendations and like the individual, like program leader, like structural level to give people actual ways that they could try to enact these constructs.

Kate Mulligan: Thank you. That sounds like a medical education scholar speaking, you know, putting tables, tables of data 

Addie McClintock: and using the words a limitation instead of. I love it. 

Kate Mulligan: And you're right. I think what struck me was using words like peace, hope, and love. In a academic medicine paper, it was just like, whoa, this this'll draw me back. So thank you for that. 

Addie McClintock: Can I add something, Kate? Sorry. Yes, of course. I just was gonna say on this topic, as we were preparing this meeting, I said, well guys, what are we gonna do if there's like a lot of discord in this room or it's a mixed audience. Sometimes people might be very quiet if there's trainees present.

And then Justin and Kate wisely were like, Addie, who's really gonna disagree with peace, love, and hope. And I was like, good point. I think we'll be okay. But um, just to say, I think. It reminded me that while we hope the paper is kind of pushing towards transformative change, it's also simple in so many, in some ways, these are back to just like our core human concepts and sort of needs and desires.

Kate Mulligan: Thanks, Addie. So next question, you describe how the system reinforces behaviors that contradict the stated institutional values of inclusion, curiosity, and vulnerability. How would you recommend faculty go about recognizing their own participation in the system? And you know what? It might be some effective ways to interrupt those patterns, maybe without alienating colleagues or disrupting team function to a point of dysfunction.

Addie McClintock: Yeah. My first thought for this question was just sort of like, well, honestly, if you're not alienating someone, you might have set your goal too low. I feel like if you're not irritating people as you push for change, then perhaps you're not really pushing for something that is going to make a.

Difference. Um, because change is hard. Most people don't like change. And this paper is in some ways, or we hope it is talking about transformative change. And we're also just sort of, um, whether it's stated explicitly or not, suggesting that those in power might be effectively asked to share it with some of these.

And sometimes people can view that loss of power as loss of control. Push back on that. We've seen that many places across our country where in this various settings, but that's in many ways, um, for some kind of a natural human response. If there's not that moment of pause. As I talked about earlier, I do think that anytime we're pushing for change, it's important to really listen to both sides.

Um, what they value, what they worry about, what are their goals, what are their hopes, um, and sort of getting as many people on board again with like, what's the shared value underneath all of this in order to push change in the ways that we want to. I think as far as recognizing our own contribution and participation, that is hard.

It comes from places of reflection and kind of personal work, personal education, and listening to what you are hearing around you or from those you work with. And again, not that others should be expected to do that work of educating you, but just like if you're in a situation that makes you uncomfortable or you're being asked to make a change and you don't like how it feels, maybe sit with that for a minute.

Ask yourself, why don't I like this? What about this? Um, there's also the exercise of five whys. Just like, ask yourself why five times in a row? Keep getting to that root of the why that you just gave, and really try to understand what that is. While I suggest reflection, I recognize that faculty already are very busy and time for reflection is pretty difficult to come by.

But I think that those are. In my mind the ways that I sort of know of to start to think about sort of our role in those spaces. And Justin, I don't know if you have anything you'd like to add there. 

Justin Bullock: Yeah, the one thing that I was thinking about as you were talking Addie, is um, I think there's a fear in being an educator like I would say to myself and other people and hearing, like from talking with other individual that, um.

At times sort of modeling vulnerability, there can be this risk or fear that you lose credibility with the people that you're teaching. There's one version that there's like theintellectual version, which is like intellectual candor, which is like sharing when you don't know something and you sort of being very open about those things.

But I also think there is a risk around that with non-intellectual things as well. One of the. Techniques that I have used, mostly because this happened, we did a study and students, they said to do this is basically I've, I try to implement in my introduction, like in sort of identity based intro, where I sort of acknowledge that like.

10 things might happen and that like, you know, we wanna collectively support like it's everyone's responsibility on the team to help support people. One example of something that happened after I started doing this was, so we did this study. I was, I think I was like second year resident maybe, and then my third year I started doing it and I had a lot of really cool introductions where I would start.

And then I usually share something by myself. Like, you know, I'm black and gay. And sometimes that comes up in different ways when I'm like caring for patients. And I've had supervisors who are like. You know, a very senior woman attending who says, like, I've been [00:24:00] attending for 20 years and I still get mislabeled for my role.

And those moments are actually really powerful because it's this kind of vulnerable sharing that really does set the tone for the team. And one time we had a team that I felt was quite well going together and there's one day where. I basically did a series of things as a senior resident. There was a patient who was dying, and I used it as a teaching moment, but the med students really were not in a place where that was well received.

I did serious things that bad and we had to debrief the next day because I was very focused on optimizing our calls day and getting us out as quick as possible. And one of the medical students basically said, you know, if that's what being a senior resident is like, I don't want to be a senior resident, and.

For me as an educator, that was actually in the moment, I felt two things. One, like, oh, like I have failed. Like I never, I never wanted to be this person, but second, I felt really proud that this person felt comfortable enough to say this very vulnerable and very critical thing about me. I do deeply believe it's because the tone that you set, it seems very like small, but I think it [00:25:00] actually propagates and so.

Sorry that was kinda a long, like winded comment after, but I think there are specific, not that time intensive interventions that people can do that can really affect people's experience of learning environments. 

[00:25:13] Kate Mulligan: Wow. Thank you. Thank you Justin. So I'm gonna skip a couple of questions and go to one that might be a, a little.

Difficult to answer as well. But when we're talking about transformative change, we obviously need more than just individual good intentions. We need some structural accountability, for example. What kinds of faculty development or evaluation metrics or institutional incentives might you like to see implemented to support the type of learning environment that we're describing?

[00:25:43] Addie McClintock: So the things that I thought of related to this question, some of which are stated in the paper, and some of which are just kind of. Addie's opinion are, I think in general I wish we had more leadership training for faculty in medicine and that I'm talking [00:26:00] really kind of nationally. I will put in a plug actually for UDub Office of Faculty Affairs, which does offer a leadership training series, offers coaching, and a number of other professional development programs, which are awesome.

Um, but. I think in general, you know, part of what happens sometimes is we don't always examine the ways in which sort of like how we were taught might just be how we teach other people without necessarily, again, that moment of reflection of like, is that really the best, most effective way to teach me something?

And I think that it faculty members. Even if you feel very junior, very early in your career and like you don't hold a quote unquote leadership role, anytime you are working in the clinical space, you really are ultimately in a leadership role. You might be leading a clinical team, um, maybe it's an interdisciplinary team, but all of those [00:27:00] places are ultimately places where a person can benefit from.

Leadership skills, I would say, you know, ultimately, sometimes, again, Addie's opinion, these leadership skills kind of boil down to like being a good person. There are things like be kind, be respectful, have empathy. Remember how difficult it was to be a trainee and again. I don't in, I don't mean to imply that people are not kind or not trying to do those things all the time, but some of the traditions in medicine were not always those things.

And so taking the minute to reflect on whether the ways that you experience training are ultimately how you hope to create for other people. Related to that, and again, I don't think this happens a ton here, but nationally I think it does still in some places, our shame-based teaching methods, everything we know about human psychology and [00:28:00] learning tells us that these are actually sort of silence promoters and they create very negative emotional memories and excess stress, and they really ultimately do not promote learning.

Another concept that, again, like the best part about this team is all the things I learned from other people, but Jennifer brought us a paper about something that is called Wise Criticism, and it's a really great paper from outside of the medical literature, more like general medical education. But the, the basic concept is that when you do give sort of feedback or criticism, it is then sort of paired with a statement to the effect of like, I'm giving you this feedback.

Because I know you are capable of something amazing and I am here to help you get there. But I think more capitalization on the practices of positive psychology and strengths-based approaches could go a long way in supporting trainees to just not feel so beaten down by the training process. And even for us, we as [00:29:00] faculty so rarely get like a thank you or great job, you know, once you're a faculty member.

You also kind of lose what could be some positive reinforcement and supports for yourself. And we often treat training as a time of looking for deficits to remedy towards a specific ideal. And of course, we should not ignore places where trainees need to grow. But there is also ways to show trainees that we recognize their accomplishments, their strengths, um, in whatever ways.

We can, I have one more and then I would like to stop being the talker, but from a metrics standpoint, we talked earlier about bias and assessment. One of the other things I think we could do, and again, I'd feel very. Proud of UDub working towards this already, but really focusing more on growth itself as a metric and not so much the end points in the way that we do with our summative assessment.

We know that whatever it is we tell trainees we will be looking for. [00:30:00] They will do so if we tell them we're looking for a. Endpoint of, you know, everything, you're ready to do it all on your own. They're not as likely to tell you that they need help and that they're, that they have not met that endpoint.

We are excellent. Figure out what to do and do it as doctors. So if we were to look to recognize growth through the ways that we evaluate trainees, we would. Find, I think that people would be looking to demonstrate growth and looking to grow as the way that they sort of experience success. And yes, every system can be gamed.

I would not pretend to say otherwise, but I think not everything that matters can necessarily be measured. I think that's also true. So again, like there are challenges to this type of approach as well. But we do still need to find ways to sort of capture what we care about so that we can reward it from a structural level.

[00:30:59] Kate Mulligan: Justin, is there something you'd like to add before I bring it open for discussion? 

Justin Bullock: The question, what do, what do we see as the bi biggest challenge to like achieving this, these goals? Again, I'm gonna go back to this project that Jennifer is leading and one of the big themes that's come up again and again and again and again.

Is this tension between trainee wellbeing and accountability, um, that the forces that be have made it. So it feels like these two things are in constant sort of tension with each other and feel like they're not both sort of accomplishable at the same time in the current framing and. To me, there's a cool opportunity to sort of re-envision how we think about those things.

 Kate Mulligan: That sounds like a great place to pause. Thank you. So I think people have been nodding and, and looking like they're. Being [00:32:00] stimulated by some of the things that were said. So thank you for the foundation about the paper, and I'd like to open the floor for questions or discussion. It was very quick that with that hand, would you like to add to our podcast?

[00:32:12] Audience: Sure. You just never know when you're gonna get pulled away and then you missed your opportunity. I really appreciate the paper and I really appreciate the premise, and I really hope that I already embody a number of the things that you suggest. And I wish to continue to grow because I would like you to measure that.

Um, uh, however, there's a tension. There's another tension. Justin, I think you brought up a really important tension that I find there is another tension between the wellbeing of faculty and the wellbeing of trainees. I'm just interested to, to hear your thoughts about that. There are some explicit suggestions in the paper that, um, you know, that give me a little bit of like raised blood pressure of, I, I struggle to do that because that is gonna [00:33:00] impact my wellbeing and then I'm not gonna be so useful for everybody or so skill.

 Justin Bullock: Thank you very much. I completely agree with your point, the question that there is absolutely a tension between those two forces and it's interesting. With program director specifically, my sense is they tend to sacrifice the self and and view that as part of their role in providing for learners, they also must navigate the wellbeing of the other faculty who are teaching the learners the dialogue.

I would say, this is Justin speaking, not literature in any way. The, the dialogue is, the learner perspective is being centered at this point in time. And I think that there's, there's like, you know, I'm imagine there's like, I'm imagining the force vector. I think it is a, a dynamic pendulum and yeah, I'm just agreeing with you without any productive further thoughts.

Yeah, I would love your thoughts. Actually. 

 Audience: There's  so much in the paper and there's so much that we can do that doesn't. I think impact our wellbeing in a negative way, in fact has a very positive effect on faculty wellbeing. Um, you know, much of the work within psychological safety, um, many of the ways in which one can speak the conversations that would be good to have, much of that is actually gonna have a really positive effect for us.

So I guess in terms of. The title of your paper. I mean, I hold onto the hope that's in that and, and then I suppose there's also, there's the hope of the future where that zero sum game becomes less zero sum. That if culture can change enough, then we can reach a place where. Working to improve something for one group of people doesn't necessarily negatively impact another, but I'm, I'm very much in so using theoretical terms there because there are definitely practical things that definitely will impact, you [00:35:00] know, my personal life and therefore my wellbeing.

And I haven't, other than, other than sort of accepting, well, I care about change, this is important enough. It's hard. 

 Kate Mulligan: Okay. Thank you for that. Would you like to go? 

 Audience: Sure. Thank you so much. This is an awesome discussion. I'm already a big fan of Dr. McClintock and it's nice to hear from you, Dr. Bullock as well.

So I'm just curious if I heard you talk a little bit about like the way you introduce yourself to a group, but when you're thinking about kind of. Changes that we can practically help to implement, whether it's undergraduate medical education or graduate medical education, if there's some kind of low hanging fruit or themes that, that you guys feel like we can be pushing forward, if that feels too random.

Maybe the other side is that is like key challenges that you're seeing that we can be. Helping to address, I'm not expecting you to tell me exactly what to do, but you can point me in certain directions if you feel like there's some stuff that we can be doing. Um, practically recognizing that, you know, we're in clinic, we're in wards, um, not all of us are program directors, for example.

 Addie McClintock: I think honestly, the thing of just the three to five minute pause in clinical work and introductions to each other is very powerful. I'm sometimes surprised when I realize that people don't always do that. I've been lucky that that's always been done for me, and so I just took for granted that that's happening in other spaces.

I do a. Front and back page orientation. When I'm gonna work with a new trainee or a student, I, I am not as good at this with GMEI will confess, but with students, a front and back page in like orientation, introduction, I kind of go over it and then I hand them the sheet. 'cause I talk too fast, I'm sure, but it just contain.

All those things. You know, it leaves space for like, hi, I'm Addie. I [00:37:00] work in this clinic. Whatever you wanna say about yourself. And then just sort of talks about expectations for the days. That's something that students really value is understanding the expectation of their work and their role in the team.

And then I do talk a little bit about like what Justin said, a quick kind of like we're all here to support each other and sort of how would anyone in the, you know, preferences a person might have for themselves about how, um, things are handled if uncomfortable situations arise. And then I do try to invite them.

Sometimes we're a little short on time and I might sort of come up to them like during lunch or later in the day and just like, oh, what, what do you wanna go into? Like, what are your learning goals for the rotation? But I think those can honestly be very short, quick, and super impactful for trainees. Um.

Especially students because they are the group that are at the lowest power differential and the newest to our environments, and so they have less of the context of sort of what the expectations [00:38:00] are compared to maybe like a resident. 

Justin Bullock: This is a slide that I often share. We did this study where we presented.

Medical students with what we thought were like very realistic scenarios of microaggressions that might happen when they're in clinical settings and ask them how they would feel most supported by their supervisors or someone who saw the these things happen. And what I was talking about is like, what do we call a pre-brief, which is just like.

Anticipatory conversation at the beginning of working together. It's the easiest for when you have sort of longitudinal relationships with people. You know, it's a little bit when people have very dynamic teams, it's kinda limitations. It's like it's harder to have an extensive pre-brief. Um, and the other just like kind of quick things that I would say from this is some of the things that I learned from myself where, you know, there are certain scenarios where it's like flagrant things happen where remaining in the room and trying to deescalate.

In the room, in the interaction is not helpful. And so in those moments, you should actually pause the interaction, step out and regroup as a team. [00:39:00] Most people, the tendency is to not do anything if something happens. But I guess our data would say that is the wrong thing to do and that you should only not do anything, which we call bearing witness, which we actually mean is not just not doing anything, but like after someone has expressed that they don't want you to do anything.

Then you only do that if someone's explicitly said that. And then the final thing is after where I trained the standard of care was like something bad happens, the whole team leaves the room. I'm in medicine, so like, you know, we're in a big team and then we debrief as a group and people just, oh, that was like really uncomfortable.

I'm sorry, I didn't know what to do. Da da. And a lot of people said that that was just sort of perform performative, allyship and not actually helpful. And instead, what is. Recommended is that you have a one-on-one with a co, with someone, Hey, I noticed this happened. Do you wanna talk about it? If they say no, you let it go.

And if they say yes, then you can talk about it. And that may be either individually or in a group. We had some learners who basically, this project sort of came out of a place where we had a learner who was [00:40:00] frequently micro aggressed and he sort of, he visually stood out compared to other learners and patients often cassette things.

Um, and at the end of his rotation, he basically. Told me and my attending, I was a senior resident this morning, he told me and my attending that he didn't find it helpful to repeatedly like debrief over and over again. He just wanted to learn medicine and didn't want to spend time talking about it. And so everyone has different preferences.

[00:40:24] Audience: One, just one question. I know we have other questions. I love that model. Thank you for sharing that. And sometimes I find when I'm working with learners and we're doing the pre-brief. They can't predict how they're gonna feel in the moment, right? So we can talk about the options in advance, but you know, every situation is different.

You can't always predict how you're gonna wanna respond. So I say, these are your menu of options. And sometimes they're like, I don't know. I mean, it, it's hard to ima, you know, I don't know how I'll feel in that moment. And so. I agree that it's helpful to [00:41:00] have a menu of options, but not everyone's ready to say, oh yeah, I'm just gonna wanna leave, or, you know?

Does that make sense? 

 Justin Bullock: Yeah. And in that case, what, what I do is hopefully nothing happens, but if something happens, then I respond in the way we've decided and I say like, how do you feel about what I did? Do you want me to still respond in the moment? I've had, for instance, someone who I was. Who told me not to respond.

I actually didn't listen to them and I responded, which is not the right thing to do, but they actually said, Hmm. I thought I would respond. And turns out, I guess I wouldn't. So thank you for, for saying something in the moment. So I don't know what the message is about that story, but you should readdress it basically.

[00:41:34] Kate Mulligan: Thank you. Would you like to. 

[00:41:37] Audience: Yeah, thanks. I'm really loving this discussion and hearing everything from your experiences and research and the article. I, I really appreciated reading. So many things have come to my mind, but I'm gonna try to focus this in a little bit, so. All of these institutions in the US are, are founded on colonial and racist ideologies, all of [00:42:00] them.

And the systems, like the medical training system and medi medical system period. And so these are really great points that have been brought up during the discussion are are excellent about like, you know, relational one-on-one or even team members. One of the biggest things that a lot of us face, one of the biggest challenges is like if, when we're doing these things, um, and then we come, uh, head to head or face to face with administrative and institutional challenges where they're so caught up in already these structures that already exist.

And then now it's even more so because we're facing from a, a government national standpoint, legal standpoint. Even all that was already a, a challenge. But now even more so pressure like against DEI, even though white women are the main beneficiaries of DEI and then a lot of things are being called DEI that aren't DEI [00:43:00] actually, um, and corporatization of.

Healthcare and even medical education. So how, what advice do you have for responding to this? Because we're, I will stick my neck out. That's okay. If I, if I lose a job, you know, I, I've got, I can get another one. But not everybody has that, um, option. And especially if you have family and you're in there, whatever, you know.

So what advice do you have to face these challenges and really push the needle forward? Because it needs to be pushed. 

[00:43:33] Kate Mulligan: Thank you. I'm gonna add in the the related question from the chat, and that is very similar to what you're saying. I think that for early career faculty in divisions with leadership that we suspect would not be supportive of the approach, what advice you have.

So I think they're related questions and that might be all we have time for. 

Justin Bullock: I love this question. So I recently gave a talk to the medical students or about identity formation, and it was, and one of the big critiques that I got from a lot of the students in my talk was like that. It was very, I'm giving individual level responses to structural problems.

So I'm gonna acknowledge that before I continue, but. For me, there's a couple things. One is I, Justin have decided to continue in this system. So there's first this decision of like whether you decide to continue in this system or not, there are people who decide to leave because they believe that change can be better affected from like being outside of the system.

I have personally decided not to do that. So first that to me that that is agency wa it can be like some people can see as defeating. For me it's like I am trying and I have always been someone who like I. Small acts of resistance. They are really healing for me. So like for me, giving someone a day off when they're not supposed to have a day off, sorry, Medicare, please don't come after my like license or whoever's like, you know.

But when I was in residency training, they always said like, you know, it's Medicare fraud if you not work on the right day and blah, blah, blah, whatever. And for me, I just found that like. Health systems don't actually care as long as the patient care gets done. So these small like actions, they do exert a cost on me, but they actually find it to be much more healing when someone can go to like their best friend's wedding.

Like for me that is my like micro resistance. And so I actually believe that those micro resistances, they add up to something very big. So to the early career faculty, you feel they might not be aligned? You know, one, I do believe it's important to understand the values of your leaders and then you can do things that.

They might agree with on the individual level, but it still seems to like fit in with the, the residency program director. What they want is for the hospital to be stacked like that is their main thing that they're worried about right now. So the way in which we. Achieve the goal we can debate about and I can just do quietly and like on my own.

Kate Mulligan: Thank you so much. I'm sure any one of us would be happy to continue the conversation, but thank you so much for joining us and thank you Addie and Justin and Amanda for all of the work that you do for CLIME and for our faculty and for pushing, pushing things forward and giving me hope so. Thank you so much.

Amanda Garza: Thanks for listening to this episode of CLIME Cast. We're grateful for Dr. Addie McClintock and Dr. Justin Bullock, along with their co-authors, Dr. Ryan Abe, Dr. Marcus Boos, and Dr. Jennifer Best for their scholarship and leadership. And to Kay Mulligan for guiding this thoughtful conversation. You can find the link to the paper and related resources in the show notes.

Until next time, thanks for being a part of the CLIME community