The Time Is Now: Teaching Psychiatry Residents to Understand and Respond to Oppression through the Development of the Human Experience Track

It is critical that physicians understand the societal forces that drive illness and unequal treatment in the USA [1]. Efforts to arm physicians in training with the skills necessary to identify, name, and eliminate mental health inequities must be a clinician-educator goal [1,2,3]. It is essential that graduate medical educators develop curricula to prepare residents to address mental health and health care disparities throughout and after training.

In response, the Yale Department of Psychiatry has developed a 4-year longitudinal Social Justice and Health Equity Curriculum (SJHEC), consisting of four tracks: Structural Competency [4, 5], Advocacy [6], History of Psychiatry, and the Human Experience. As part of the core residency curriculum, trainees attend sessions in all four tracks with a collective mission of creating a generation of psychiatrists equipped to eradicate mental health disparities. This manuscript will describe the Human Experience (HE) Track, which aims to illuminate systems of power and oppression within ourselves and society and teach trainees clinical practice interventions to mitigate inequities caused by these systems. The HE Track draws on the social sciences, humanities, and psychological theories; residents are taught how to see and respond to societal, institutional, and individual manifestations of oppression (such as racism, sexism, heterosexism, ableism, classism, ageism, and anti-Semitism) and understand how they contribute to disparities. To our knowledge, there are very few similar curricula within psychiatry training programs [2, 6, 7].

This manuscript aims to first outline the development and implementation of the pilot HE Track within the SJHEC and second, to describe critical feedback from residents and facilitators used to inform subsequent iterations of the curriculum. We will outline our resident feedback and how it was incorporated to improve the curriculum in six lessons learned and aspire to support others in developing and revising similar curricula.

Curriculum Development and Implementation

The HE Track’s mission and curriculum was developed by a group of key stakeholders, including multidisciplinary faculty and psychiatry residents from all years, drawing upon selected courses that were previously initiated in an ad-hoc manner. We implemented the pilot curriculum within the PGY2 cohort in Spring 2018 under the name of the Social Sciences Track (later renamed the Human Experience Track). The initial goal was to provide PGY-2 psychiatry residents with theoretical principles that could be practically applied and to empower residents to address health disparities in clinical work.

A series of topics were chosen for the curriculum based on a needs assessment led and completed by then-current PGY-2 residents. Three residents met with their PGY-2 cohort and inquired about what social science topics they would like included. This feedback was presented to the class for revisions and then presented to the curriculum’s faculty leaders. From there, faculty leaders of the HE Track recruited content experts in the relevant fields of social science to create session content.

The HE Track was implemented over seven 90-minute sessions (see Table 1) in the Fall of 2018 and Spring of 2019. Facilitators were from various departments, including anthropology, history of medicine, sociology, and psychiatry (including residents). Additional resources for the curriculum included pre-assigned non-mandatory readings.

Table 1 Resident focus group feedback related to pilot human experience sessions

Curriculum Evaluation and Feedback Sessions

We studied the curriculum’s acceptability and accessibility from the residents’ perspective and collected reflections on implementation by session facilitators. Three opportunities were offered for residents to provide feedback in the form of post-session focused feedback groups. We also received feedback from a PGY-2 resident representative and residents one-on-one if they could not attend a feedback session. Additionally, we conducted similar individual interviews with the session facilitators several months afterward to acquire feedback. Resident focus groups and facilitator interviews were deemed IRB exempt.

Residents and facilitators were informed that participation in feedback sessions was optional and would be anonymous and de-identified. No audio recording occurred to facilitate transparent conversation. The Rapid Assessment Approach was used to take notes.

Three research team members independently reviewed all feedback, including the resident focus group and facilitator interview notes for themes. Then, in dyads, these members met to compare and reach a consensus on themes. Following this, all three members met to reach a final list of key themes and findings. A conventional content analysis approach was used to derive themes and ensure saturation. To assure validity, a summary of themes discussed was offered to the participants, with the opportunity for modification.

Resident Focus Group and Facilitator Feedback

A total of 14 PGY-2 psychiatry residents provided feedback out of a cohort of 20 residents. Feedback is described in Table 1 [8].

Facilitator feedback consisted of three themes. First, many facilitators from outside the department wanted to know the training residents had already received and about their diversity of experiences and backgrounds. Second, some facilitators suggested being paired with someone in psychiatry, to ensure material was clinically relevant. Lastly, a co-facilitator could help facilitate the group process and dialogue that develops.

Progression of the Curriculum Mission

We initially aimed to empower residents with theoretical principles that can be applied practically to minimize health disparities in clinical work by having experts from the social sciences work with clinical psychiatry facilitators to design and implement material. Focusing on the social sciences and humanities can allow residents to gain a skill set in exploring the subjective and individual experiences of patients, while also valuing the collective experience of varying social groups and cultures, including their own.

Due to time limitations, there was less opportunity for interdisciplinary collaboration with facilitators from the social sciences. This led to material heavily weighted in theory rather than a focus on clinical application. Additionally, solution generation is a challenge which may have led to less session time devoted to it. With resident feedback, we re-conceptualized the curriculum’s mission to focus on making concepts from the social sciences more clinically relevant. The revised and current HE Track mission aims to illuminate systems of power and oppression within ourselves and society and teach trainees clinical practice interventions to mitigate inequities caused by these systems. This complements the other tracks, which focus on addressing structural factors that impact disparities (Structural Competency), advocating on multiple levels for equitable patient care (Advocacy), and historical origins of oppression as well as the roots of disparities in psychiatry (History of Psychiatry).

Lessons Learned from Resident Feedback

Social Sciences Must Be Taught in a Clinically Relevant Context

A large shift in the curriculum has been to strategically make use of social science expertise to address pertinent clinical issues. The emphasis on oppressive societal forces (such as racism, sexism, heterosexism, ableism, classism, ageism, and anti-Semitism) is now central to the mission of the HE curriculum, utilizing a pedagogy based on patient-centered and case-based learning. This use of cases has been described in both medical schools and residency’s social science curriculum and is now emphasized [7, 9].

Residents Crave Content that Is Developmentally Appropriate to their Stage of Training

Content that asks residents to critically examine a psychiatrist’s role related to patient autonomy, social responsibility, and the legal system may not be developmentally appropriate during the first and second years when residents are still solidifying fundamental clinical knowledge. One participant shared that the ability to “discuss cases” would add value. Utilizing a case-based pedagogy aligns the content to be developmentally appropriate, as cases can be tailored to learner needs.

An additional challenge may be teaching learners with varying levels of content experience. To address this, we provided an array of primary readings to engage with ahead of sessions. Learners could then use readings to explore foundational material or expand existing frameworks.

Non-physician Facilitators May Be more Effective if Paired with Clinicians

Future iterations would benefit from having physician co-facilitators for sessions led by non-physicians (social scientists such as anthropologists, sociologists, and historians). It is difficult for someone outside of the field to fully understand residency training. A participant shared that one session “presented the building blocks, and we could use more advanced work.” Adding a clinical partner would advance the sessions’ depth and applicability, which now occurs with sessions.

Time for Reflection Is Key

We aspire to offer transformative learning in our curriculum, which is part of the comprehensive SJHEC goal. This requires time for critical reflection of one’s own assumptions to see changes in key areas related to social activism [10, 11]. Reflection time must be built into sessions and viewed as vital to processing the content and physician development [12]. Additionally, allowing trainees to provide feedback may help facilitate reflection and significantly advance the curriculum. Future iterations of the curriculum now have built-in reflection time.

Topics of Power, Race, and Class Can Create Personal and Inter-group Tensions that Must Be Addressed Upfront and Throughout the Course

As we discuss and deconstruct topics such as power, race, and class, there are inherent tensions that can be anticipated and addressed. For many learners, these topics are not novel phenomena being presented in a clinical context; instead, they are oppressive forces that have and continue to impact their daily lives [13]. Asking residents to delve into such difficult topics can be challenging at best and re-traumatizing at worst. Residents who identify with dominant groups may carry different lived experiences with these concepts and can feel guilty, afraid of saying the wrong thing, or attacked [14]. These tensions of guilt, fear, and other intra-personal tensions must be anticipated and addressed upfront and throughout the course. Additionally, facilitators bring their own views and lived experiences to these topics, which can impact how the material is delivered and received. Moreover, it may not be uncommon for the social, political, and economic forces outside of the classroom to manifest in the classroom in ways that facilitators need to be alert to, prepared for, and when possible, able to weave into the learning for residents. These dynamics, however challenging, can become a focus for a collaborative inquiry and growth.

Classroom outcomes can include tension and resistance that takes on the form of silence, defensiveness, and dismissiveness, as well as a replication of dominant structures of power that marginalize non-majority groups [15, 16]. As track leaders, there may have been times of class silence or sentiments of defensiveness that the initial iterations of the curriculum could have addressed in real-time. In subsequent iterations, these tensions have been proactively acknowledged and addressed. One study suggests that there are common instructional challenges that can be anticipated when discussing topics such as race that include post-racial beliefs (racism is an issue of the past), resistance to learning, dialogues that breed aggressive comments and behaviors, and race as otherness [17]. The learning space and facilitators must be equipped to anticipate and address the diverse array of perspectives, lived experience, and dissent that may occur. Facilitators now have dedicated time to their own development through accessing primary literature and peer supervision before and after offered sessions. We also now have consistent facilitators representative of the significant axes of difference in the classroom for sessions. Additionally, SJHEC leadership attends selected sessions to offer constructive facilitator feedback. Training and having a diversity of experiences among track leaders and facilitators, as well as proactively anticipating, acknowledging, and addressing tensions, and creating learning spaces that allow for a diversity of perspectives are all essential factors in addressing tensions that may arise and in doing this work.

Prior literature from social justice educators challenges the beliefs of creating “safe” spaces [18]. It argues that there may be no truly safe spaces when teaching a diverse array of learners who have experienced oppressive societal forces [18]. Tools that have been suggested to address the inherent challenges include normalizing difficulty by acknowledging in advance that confronting these topics and personally held beliefs creates discomfort [15, 19]. Additional strategies include incorporating diverse forms of reflection (written, peer to peer) and using critical learning journals to provide a private space to reflect [17].

Learning Objectives Need to Be Explicitly Stated and Require Continual Refining

Learning objectives must align with the track’s mission and be overtly stated. In initial iterations of the curriculum and implicit bias session, the learning objectives were too broad, asking residents to develop an understanding of how implicit bias contributes to disparities. In subsequent iterations, in response to the residents’ feedback, we further detailed the learning objective to “Examining bias in human relationships: recognize and describe cognitive biases that may lead to diagnostic errors.” This was followed by a session to facilitate reflection and discuss practical cognitive de-biasing solutions. Additionally, it is imperative that we consult the existing literature on developing social justice health equity curricula [2,3,4,5,6,7, 9, 17, 18]. We are also utilizing expert consultation, supported by Yale Department of Psychiatry interest and funding, to ensure the work is dynamic, continually refined, and attuned to the climate of oppressive societal forces. The ongoing needs assessments from learners and continued involvement of residents also ensure that objectives remain relevant to topics impacting patient care as it relates to social justice and health equity.

Curriculum Planning Considerations

Not every residency program has social science experts, thus requiring creativity and resourcefulness in building similar curricular offerings. Program to program consultation may offer opportunities to brainstorm solutions. It may also be challenging to pair psychiatrists with social scientists, given time restrictions. Additionally, it may be challenging to allocate curricular time for additional content, making it imperative to incorporate learning opportunities in clinical settings.

The experiences of our trainees may not be generalizable. Additionally, it is crucial to account for varying resident experiences. The focus feedback groups may limit residents’ ability to share transparently. Further studies are needed to assess if the curriculum leads to changes in attitudes and decision making over a longitudinal period.

Having sufficient individual and group support for trainees with or without such classes is key.

Additionally, it may be frustrating and possibly have a negative impact on trainees to have this curriculum without a space to enact change. One way to address this may be to encourage scholarly projects around social justice and health equity to serve as an immediate outlet for addressing inequities.

Now, more than ever, it is crucial that training physicians understand the oppressive social forces that drive health inequality. Equally important to this curriculum’s content was how it was developed, how it is continually shaped, and the commitment to refine and build upon its existence. For educators aspiring to create a similar curriculum, there must be adequate attention drawn to development, continual iteration, thoughtful anticipation of areas for growth and tension, and inclusion of critical stakeholders, which most importantly includes your learners.

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Acknowledgments

Dr. Balasuriya is supported by the Yale National Clinician Scholars Program and by CTSA Grant Number TL1 TR001864 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH). Dr. Balasuryia is also supported by the U.S. Department of Veterans Affairs (VA) Office of Academic Affiliations through the VA/National Clinician Scholars Program and Yale University. Dr. Balasuriya’s time was made possible from support provided by the VA Office of Academic Affiliations through the VA/National Clinician Scholars Program and Yale University. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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Correspondence to Lilanthi Balasuriya.

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Dr. Rohrbaugh is an Academic Psychiatry editorial board member. Manuscripts that are authored by a member of the Editorial Board undergo the same editorial review process applied to all manuscripts, including double-blinded peer review. On behalf of the remaining authors, the corresponding author states that there is no conflict of interest.

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Study was deemed exempt by the IRB.

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Dr. Rohrbaugh is an Academic Psychiatry editorial board member. Manuscripts that are authored by a member of the Editorial Board undergo the same editorial review process applied to all manuscripts, including double-blinded peer review. On behalf of the remaining authors, the corresponding author states that there is no conflict of interest.

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Balasuriya, L., Isom, J., Cyrus, K. et al. The Time Is Now: Teaching Psychiatry Residents to Understand and Respond to Oppression through the Development of the Human Experience Track. Acad Psychiatry 45, 78–83 (2021). https://doi.org/10.1007/s40596-021-01399-x

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