Inclusion in the clinical learning environment: Building the conditions for diverse human flourishing

Abstract

Aim: While diversity, equity, and inclusion are much proclaimed aspirational goals in education programs, the clinical learning environment (CLE) frequently falls short of meaningful incorporation of these concepts in processes, policies, and local culture. In this paper, we explore how inclusion, diversity, and equity can and should be defined and operationalized within medical education.
Methods: Three cases, organized around Hafferty’s curricular framework (formal, informal, and hidden), we illustrate lapses and potential best practices in inclusion in the CLE.
Results: The essential “best-practice” of programs inclusive of diverse individuals is the design of policies, processes, and behavioral norms co-creatively with all community members. Potential pitfalls to greater inclusion include nostalgic reference to “the past”, a neutrality that is operationalized without the rudder of explicit values and not recognizing that ethical obligations between teachers, learners, and programs are at the heart of the discussion of how inclusive learning and work environments are built.
Conclusion: Inclusive CLE’s provide space for co-creation, understand the need to ensure the voices of the vulnerable (i.e. learners) are heard and valued and through this promote the flourishing of diverse human capital, in keeping with a model that views diversity as a key attribute or organizational excellence.

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Inclusion in the clinical learning environment:
Building the conditions for diverse human
flourishing
Saleem Razack & Ingrid Philibert
To cite this article: Saleem Razack & Ingrid Philibert (2019): Inclusion in the clinical learning
environment: Building the conditions for diverse human flourishing, Medical Teacher, DOI:
10.1080/0142159X.2019.1566600
To link to this article: https://doi.org/10.1080/0142159X.2019.1566600
Published online: 22 Feb 2019.
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Inclusion in the clinical learning environment: Building the conditions for
diverse human flourishing
Saleem Razack
a
and Ingrid Philibert
b
a
Pediatrics, Centre for Medical Education, and Office of Social Accountability and Community Engagement, Faculty of Medicine, McGill
University, Montreal, Canada;
b
Department of Field Activities, Accreditation Council for Graduate Medical Education, Chicago, IL
ABSTRACT
Aim: While diversity, equity, and inclusion are much proclaimed aspirational goals in education programs, the clinical learn-
ing environment (CLE) frequently falls short of meaningful incorporation of these concepts in processes, policies, and local
culture. In this paper, we explore how inclusion, diversity, and equity can and should be defined and operationalized within
medical education.
Methods: Three cases, organized around Hafferty’s curricular framework (formal, informal, and hidden), we illustrate lapses
and potential best practices in inclusion in the CLE.
Results: The essential “best-practice”of programs inclusive of diverse individuals is the design of policies, processes, and
behavioral norms co-creatively with all community members. Potential pitfalls to greater inclusion include nostalgic refer-
ence to “the past”, a neutrality that is operationalized without the rudder of explicit values and not recognizing that ethical
obligations between teachers, learners, and programs are at the heart of the discussion of how inclusive learning and work
environments are built.
Conclusion: Inclusive CLE’s provide space for co-creation, understand the need to ensure the voices of the vulnerable (i.e.
learners) are heard and valued and through this promote the flourishing of diverse human capital, in keeping with a model
that views diversity as a key attribute or organizational excellence.
Introduction
Diversity and inclusion encompass acceptance of and
respect for the attributes of individuals along socially
meaningful dimensions of difference. In different societies,
meaningful dimensions may vary, but typically include
ones such as race, ethnicity, gender, sexual orientation,
socio-economic status, age, religious beliefs or other attrib-
utes. Inclusion, diversity, and equity are abundantly pro-
claimed aspirations in most medical education programs
and are rooted in an ethos of fairness and respect in
learner-teacher, learner-learner, and learner-colleague rela-
tionships. Yet, the clinical learning environment (CLE) in
many medical education programs often falls short of
meaningful incorporation of the concepts of diversity,
equity, and inclusion into processes, policy and program
culture (Liebschutz et al. 2006, Beagan 2003, and AAMC
2014). Instead, these concepts find difficulty progressing
beyond vague platitudes on program websites and the
like, with little usefulness in the real world of trainees’lived
experiences within their programs.
In medical education, there have been frequent and
high-level calls to increase diversity (Association of
Faculties of Medicine of Canada 2010 and Josiah Macy Jr.
Foundation 2008). These calls have met with variable suc-
cess. Medical school classes have become majority women
in North America, and are ethnically more diverse than pre-
viously. However, within this apparent increasing diversity,
there are important pockets of underrepresentation of per-
sons from historically marginalized groups (Young et al.
2012 and AAMC 2014). In addition, women are
underrepresented in leadership positions in teaching insti-
tutions (Carr et al. 2015, Rochon et al. 2016).
The CLE is defined as the cultural norms and institutional
practicesthatlearnersexperiencethroughthecourseoftheir
learning, whenever and wherever they gather to learn
(Maudsley 2001). With respect to diversity and inclusion, prob-
lems with the CLE comprise issues that are both structural
and relational. Structural issues include systemic barriers that
might be experienced by persons from specific groups to par-
ticipation within programs, while relational impediments
might include mistreatment experienced by diverse persons
based on the group to which they belong. In a study of
minority residents in the United States, 3 major CLE themes
were described: frequent episodes of microaggressions and
bias, minority residents tasked as race/ethnicity ambassadors,
and challenges negotiating professional and personal identity,
while seen as “other.”(Osseo-Asare et al. 2018)
Shore et al. (2011) defined inclusion as a series of insti-
tutional practices and cultural norms which promote a
high sense of belongingness of individuals within organiza-
tions or institutions, while simultaneously recognizing and
valuing individuals’uniqueness. Belongingness is fostered
through minimization of hierarchical decision-making and
attention to the safety of the CLE, while recognition of indi-
viduals’uniqueness might include a willingness to alter
practice to accommodate diverse persons.
Diversity, at its core, is best characterized not as a
“problem”to be dealt with, but rather, as a fundamental
property of populations (Razack 2018). Populations are
defined by what they share (e.g. trainees in a program).
CONTACT Saleem Razack saleem.razack@mcgill.ca Centre for Medical Education, Office of Social Accountability and Community Engagement, Faculty
of Medicine, McGill University, Montreal, Canada.
ß2019 Informa UK Limited, trading as Taylor & Francis Group
MEDICAL TEACHER
https://doi.org/10.1080/0142159X.2019.1566600

The “diversity”of a population is simply the characteristics
not shared by all members –in the example of trainees
above, how they may differ in their gender, race, and sex-
ual orientation, etc. Context defines the domains that mat-
ter, which results in actions on the part of programs.
Actions might include committing to track data or to
develop and implement policies that address the concerns
of members of specific groups. From an outcomes perspec-
tive, diversity is becoming recognized as an attribute of
excellent organizations within medical education (Nivet
2011 and Nivet 2015), with this further supported by show-
ing that diversity and inclusion in the physician workforce
increase access for underserved patients (Marrast et al.
2014). Beyond being important to their experience in the
CLE, data suggests inclusion is important to educational
attainment for non-majority learners in postgraduate med-
ical education programs (Woolf et al. 2016).
A related concept to diversity, and one which impacts
heavily on inclusion issues in the CLE is the construct of
“equity”. Equity is about recognizing historical and current
marginalization experienced by members of certain groups
within society, and understanding institutions as places
where the injustices have occurred.
In analyzing issues within the CLE, a useful framework is
to consider training in postgraduate medicine as a curricu-
lum, with formal, informal and hidden components
(Hafferty 1998). The formal curriculum consists of “what we
say we teach”–required rotations, educational sessions
and the like. The informal curriculum consists of the behav-
ioral norms in the CLE that govern the interactions
between teachers, learners, and other agents within a
milieu during the course of learning. The hidden curriculum
consists of institutional policies and practices which serve
to reinforce certain actions and constrain others (Hafferty
1998, Martimianakis et al. 2015 and Muntinga et al. 2016).
In this paper we will take the concepts of inclusion,
equity and diversity from meaningful definition to concrete
action within residency programs, exploring how each term
has been conceptualized and problematized within medical
education, through several representative cases.
Case analysis
Case 1: Didactic teaching
Within a urology training program, didactic teaching has
been held since its inception on Wednesdays between 5
and 8:30 pm at night. Two residents, Jill and Jacques, have
consistently had poor attendance at this activity, missing
greater than 50% of the sessions. Jill has 2-year-old twins
at home. Jill states that the period between 5 and 7:30 pm
is incredibly active for the kids. She misses it frequently for
her on-call duties and needs to prioritize family life when
not on call. Jacques has a 7-year-old and a 9-year-old and
is recently divorced. The divorce is acrimonious with very
strict shared custody apportionment. Evenings (5–7:30 pm)
are important family times. Jacques has the children every
second Wednesday, has no stable child care for that time,
and wants to spend time with the children.
In this case example, the hidden curriculum is the sali-
ent aspect of learning that might threaten the inclusivity of
the CLE. The institutional practice of having academic
teaching sessions in the evening constrains the participa-
tion of residents who might be parents with significant
caregiving responsibilities. This can be analyzed as a form
of systematic exclusion, because residency training is often
undertaken by persons of childbearing age, and a signifi-
cant portion of them might be parents. An equity issue
might also be raised with this case –presumably, the prac-
tice evolved the way it has because in the past, most resi-
dents would not have had primary caregiver responsibility.
The implications for inclusion policies certainly involve
the ultimate output of policy–will the time of teaching be
changed or not?—but really have to do with the process
by which decisions are made. Inclusive programs display
the courage to co-create with their learners the conditions
(policies and procedures) under which all will operate
within the bounds of training, and commit to using broad
sources of data to make decisions. Co-creation does not
imply an abdication of decision-making responsibility solely
to learners, but rather committing to policy development
with minimization of hierarchies and respecting the voices
of all who might be affected by the policies.
Case 2: Rounding on indigenous patients with an
indigenous trainee
In the pediatric critical care unit, the night resident is
Hannah, who is a member of an Indigenous group in the
country where training is taking place. By her outside
appearance, she is not visibly identifiable as Indigenous
and a member of a minority group. She is transferring care
to the day team of trainees with supervisor Dr. Zahid.
There are 3 patients from various Indigenous communities,
all infants with respiratory infections and very similar sto-
ries. Some team members point out that the unit occu-
pancy versus population share for Indigenous patients is
very skewed, with one-quarter of the beds occupied by
Indigenous patients, versus a 1% population share. Team
members ponder potential causes, wondering aloud if
there are issues with hygiene and child care in these north-
ern communities that promote respiratory illnesses. The
language used contains many instances of casual stereo-
typing and factual inaccuracies. Hannah discloses her
Indigenous status. The team’s way of discussing these
patients changes with the disclosure and some team mem-
bers are visibly embarrassed at their previous “othering”
language. Dr. Zahid seems unsure how to proceed.
In this case example, the salient aspect of the CLE to
analyze is the informal curriculum—the behavioral norms
Practice points
Inclusive practices include: recognizing unique-
ness and promoting belongingness.
Diversity is a fundamental property of populations
and not a “problem”to be fixed.
Equity addresses ongoing injustices experienced
by marginalized persons.
Inclusive spaces are co-creative.
Beware of nostalgia, neutrality and conflated out-
comes in inclusion discussions.
2 S. RAZACK AND I. PHILIBERT

and “cultural”practices of the actors within it, with atten-
tion to its empowered members. The medical team’s
speculation about child care practices of Indigenous
parents constitutes “othering,”a process that identifies
individuals and groups that are considered different from
the “mainstream”and that can be used to create or
reinforce positions of domination (Johnson et al. 2014 and
Said 1993). The Indigenous resident’s experiences can be
classified as a microaggression, defined as small verbaliza-
tions or other behaviors experienced by the recipient as
biased in some way on the basis of his or her group
belonging (racist, sexist, homophobic etc.) (Sue et al. 2007).
The responses of the powerful (i.e. the supervisors) and the
collective (fellow learners) are keys to determining the
effect of the experience as a threat. Significant distress can
also arise within learners who witness microaggressions
but who, for reasons of disempowerment, fail to act at the
moment (Dover 2016). Anti-racism training often focuses
on giving witnesses the tools to speak up at the moment
for this reason (Wing Sue et al. 2009).
Dr. Zahid’s lack of clarity as to how to proceed in Case 2
demonstrates the importance of faculty development in influ-
encing behavioral norms within the CLE towards greater
inclusion, giving teachers the tools to label issues as they
arise (“microaggression”,“othering”) and skill-building to sen-
sitively debrief them for transformative learning. Underlying
any faculty development aimed at inclusion is the notion of
building critical consciousness capacity. Critical consciousness,
a term coined by Brazilian educator Paulo Freire, focuses on
achieving an in-depth understanding of the world, allowing
for the perception and exposure of social and political con-
tradictions. Critical consciousness also includes taking action
against the oppressive elements in one’s milieu that are illu-
minated by that understanding (Kumagai and Lypson 2009).
In critically conscious faculty development aimed at enhanc-
ing understanding of biases (Harris et al. 2016)andincreas-
ing inclusion in the CLE, the perceptions that need to be
developed are an appreciation of structural racism, oppres-
sion, and marginalization. Teachers equipped with these tools
are then able to examine the language used in teaching. Is it
free of othering terminology?
Case 3: Queer family building
Medical student concerns are next on the agenda at the cur-
riculum committee. Louis-Charles, the student representative
on the committee, raises the following issue brought to him
by a student undertaking an infertility elective. This student
was assigned to an in vitro fertilization clinic and recently
encountered a Gay couple and their surrogate who were
consulting for IVF through surrogacy. Indeed, the student
was surprised that the clinic had a fulltime nurse assigned
to “LGBT family building”. The student asked whether there
should be a session in the curriculum on queer family build-
ing. Several senior members of the committee dismiss the
idea. One faculty member states, “It is not our responsibility
to teach about how two men build a family.”
In this case, it is the formal curriculum that comes into
salience with respect to the CLE. Most analyses of the CLE
concentrate on informal behaviors and hidden practices
rather than the formal curriculum. We argue for an enlarged
definition of what constitutes the CLE, as the formal
curriculum can be understood as an object within the CLE,
just as capable of manifesting inclusion and exclusion as
other parts of it (Ly and Crowshoe 2015). The issue, in this
case, is the notion of representativeness—how are the med-
ical concerns of diverse groups portrayed in what is learned?
Damon Tweedy (2015), an African American psychiatrist in
the United States, has written a poignant memoir entitled,
“Black Man in a White Coat”, which describes his experience
as a student in medical school, and his learning about how
his own people’s health problems and behaviors were being
represented within the formal curriculum, and the experi-
ence of threat, stereotyping and othering (and inaccuracies)
that such portrayals produced within him and the other
black students in his classes.
Discussion
Building inclusive spaces for dialogue
How can spaces that are welcoming of diversity and mind-
ful of equity be purposefully built within programs for
greater inclusion in the CLE? The answer lies in having a
multipronged approach that is committed to the notion of
co-creation—that is, of building a CLE that the rules of
which, whether they be informal and formal, both learners
and teachers co-construct, with each group contributing
their experience and expertise to the process. If case one
highlights more of a “top-down”approach, focusing on
policy and process, case two suggests a need for “bottom-
up”strategies as well —with educational approaches for
both teachers and learners that encourage critical con-
sciousness and transformation. Case 3 brings to the fore
that the formal curriculum is not an innocent bystander in
the CLE, but can also be a powerful agent in processes of
inclusion and alienation. Curricular development and gov-
ernance also must be co-creative and indeed should ideally
involve the patient voice as well.
What form should co-creation take? Learners and teach-
ers must be engaged in all forums where decisions are
made, with learners’expertise recognized in the discus-
sions, to avoid tokenism. Curricular governance, policy
development, and solution-finding committees must com-
mit to hearing the voices of diverse stakeholders. Rigorous
policies for dealing with lapses in the inclusion or regulat-
ing the terms of inclusion often exist in institutions and
within programs. However, their application and enforce-
ment can lag behind the stated values. Individuals in lead-
ership positions must commit to enacting the will of
stakeholders as expressed through policy. Finally, true
transformation can only occur through dialog. Effective dia-
log requires a commitment to addressing critically and
explicitly any concerns raised, in ways that privilege the
voices of the vulnerable (i.e. learners), recognizing that one
of the reasons people do not raise concerns is because of
the fear of reprisal as disempowered members of groups.
Avoiding the pitfalls of nostalgia, neutrality, and
conflated outcomes
Nostalgia is a pitfall frequently encountered in inclusion
discussions that go awry. When behavioral norms are ques-
tioned that previously have not been questioned, there
MEDICAL TEACHER 3

may be a tendency to look back to a golden past when
one did not need to be so “politically correct”. For instance,
if a faculty member shows exasperation at having his com-
ment that a trainee is a “fine gal”be questioned, stating
that in the past this would have been seen as a compli-
ment, how does one respond? On the one hand, it is genu-
inely possible that behavioral norms are evolving. On the
other hand, the narratives of the past that generally get
remembered nostalgically are those of the empowered. Did
female residents from the imagined past, where it was
acceptable to say “fine gals,”consider that terminology
appropriate at the time or were they just too disempow-
ered to speak up? Appreciating nostalgic pasts through the
lens of narratives of the powerful runs the risk of dishonor-
ing those marginalized by those histories, and creates
unhelpful barriers to progress in the present.
A second pitfall encountered in inclusion discussions
related to the CLE is that of “neutrality”or “impartiality”.
We refer here particularly to how leadership might set the
stage for discussions around conflicts in the CLE. Terms
used might include “hearing both sides”or similar phras-
ing. For instance, in the case with the learner above, the
Indigenous learner perspective (perceiving the microag-
gression) might be contrasted with the ignorance (lack of
familiarity with the issues and not mean-spiritedness) on
the part of the other learners. The CLE essentially made
invisible the possibility that one of the learners could be
Indigenous, and none of the others within it was equipped
to question the narrative of othering of Indigenous patients
that took place, causing the space to function as a coloniz-
ing one for the Indigenous learner. A debrief that fails to
recognize this issue and instead focuses on “hearing both
sides”would run the risk of being itself unsafe for the
Indigenous learner. Instead of neutrality or impartiality, a
better approach in these types of difficult discussions is to
explicitly recognize the values (inclusion, mutual respect,
diminution of hierarchies) guiding the discussion at
the outset.
A third pitfall encountered in inclusion discussions is
one of the conflated outcomes. The justification goes
something like this: improve the CLE and better and more
open communication ensues; improving communication
leads to better health outcomes for patients. To frame the
discussion this way is not untrue, but only tells one half of
the story and not the half that started the discussion in the
first place. Discussions of the CLE and how it should be are
about the ethics of medical education—teachers’and pro-
grams’obligations towards their students, and how best to
define them. Indeed, we must ask ourselves how power
and hierarchy are operating such that it is easier to talk
about improving patient outcomes in issues related to the
CLE, rather than discussing the ethical obligations of teach-
ers in medical education.
Moving forward towards more inclusive learning
environments
A courageous commitment to co-creation in all processes
is the key to building inclusive CLE’s. This implies stake-
holder partnerships and integration in the design and man-
agement of the CLE, within a framework of diminished
hierarchies. An ethos of co-creation between programs,
teachers, and learners can feel like moving from a well-
manicured garden to an untended and overgrown wood,
with unknowns lurking at every corner. It means relinquish-
ing some control over the outcomes of discussions and
recognizing that specific expertise exists within all stake-
holders, learners, and teachers alike. In spaces where these
discussions take place, we must be explicit to embed the
principles of critical consciousness, mutual respect, and rec-
ognition of the need to hear all stakeholder voices, which
might require strategies that privilege the voices of the vul-
nerable. If true co-creation can be accomplished, we will
be able to move beyond the platitudinous with respect to
equity, diversity, and inclusion within medical education,
and to engage thoughtfully in transformational policy and
culture change for the flourishing of the diverse human
capital that comprises our learner population.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the article.
Acknowledgments
This work was originally presented in a workshop format at the
International Conference on Residency Education, Halifax, Nova Scotia,
Canada on October 17, 2018. The author acknowledges the discus-
sions had there with the conference attendees: Linda Snell, Nicolette
Caccia, Elizabeth Elsey, Ric Almond, Andrew Warren, Anne Matlow,
and Kelly Caverzagie.
Notes on contributors
Saleem Razack, MD, is a Professor of Pediatrics, Member of the
Centre for Medical Education, and Director of the Office of Social
Accountability and Community Engagement, Faculty of Medicine,
McGill University, Montreal, Canada.
Ingrid Philibert, PhD, is a writer and editor in medical education and
the former Senior Vice President, Field Activities, Accreditation Council
for Graduate Medical Education, Chicago, IL.
ORCID
Saleem Razack http://orcid.org/0000-0002-4834-4289
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