We received expressions of interest from 69 individuals, 52 (75%) of whom joined one of five sessions (median, 11 participants per session; range, 8 to 12). Volunteers were primarily physicians (n = 37, 71%), 19 of them senior trainees (37%). They self-identified as female (60%), Black (35%), and Latinx / Hispanic (13%). We intentionally oversampled Black participants: one-third in our sample, compared to the 2019 US census average of 13.4%. We developed a behavioral typology based on the qualitative analysis of participants’ contributions. This corpus comprised 260 free-text entries (noted with an S, for "Session," in the sections that follow), five transcribed debriefing sessions (noted with a D, for “Debriefing”), and written reflections submitted by 32 (62%) participants two or more weeks after their index session (median, three weeks; range, 2 to 7; noted with an F, for “Follow-up”). We organized behaviors around five interlocking domains, each with a graded range of possible approaches supervisors could resort to when confronting similar challenges.
Toward a typology of supervisors’ sesponses to racist actions
1. Gradation: from conciliatory to confrontational
In response to a racist interaction, an overt approach resonated with some participants on the "step in, step up, shut (him) up" (S1) side of the spectrum, one in which "my dignity is more important than my position," (S2) and where they deemed alternatives to confrontation as unrealistic. From this perspective, absent forceful engagement with its source would risk perpetuating and tolerating similar behaviors in the future—consistent with prior experience, in which little systemic protection had taken place:
Rather than negotiating or dialoguing with patients and their families, there needs to be a boundary of absolutely no tolerance. (S3)
Others worried about a sudden and uncalled-for rush to action, advocating instead for a measured approach. By adjusting the intensity and slowing the timing of the response, they sought to balance an overriding clinical duty to the patient with the necessary support of the trainee. They advocated for behavioral scaling, concerned that forceful confrontation could exacerbate tensions and poor outcomes and defeat the building of necessary skills, such as alternative approaches through dialogue toward a middle ground of understanding:
A rush to action at the expense of reflection defies most models of leadership, which insist leaders must “get on the balcony” to see the whole picture before making a decision. How do we all become courageous instead of cowardly or rash in the face of conflict and injury is a core question here. My hope is that by pausing and going from the “arena” to the “balcony," we won’t be inadvertently deemed as racist and so foreclose dialogue, but instead move toward mutual clarification, support, and growth for all parties. (F1)
Participants who had been on the receiving end of racialized attacks one time too many had limited trust in conciliation and efforts that they considered coddling of the aggressor rather than supporting a trainee in a subordinate position and at a disadvantage to standing up for themselves. They wanted to return to their clinical duties unencumbered and protected from hurtful acts in which there were no morally equivalent two sides: “Nasty racist patients are not going anywhere, but neither am I.” (S4)
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2. Explicitness: from eliding to naming
Talking about the emotionally charged topic of racism is inherently tricky. However, labeling inappropriate behaviors and hurtful actions can be a practical entry point. Just as language shapes our understanding of the world and our actions, terminology to deconstruct racialized acts can put into words what otherwise goes unsaid –but not unfelt. Most participants found the terminology of the didactic component to be helpful: disambiguating racism from racist acts or considering alternatives to euphemistic terms (e.g., "racism-conscious" instead of race-conscious"). Many agreed that acknowledging and addressing racism starts with naming actions for what they are.
Respondents differed in their views of when best to name terms explicitly and use them for good rather than potentially weaponize them. Some conceded that naming racism may or may not be advisable with the offending party in a given clinical situation but must always be addressed when supporting the aggrieved party. For example, a supervisor who does not recognize a racial injury has work ahead and further personal growth; by contrast, a supervisor who does become aware of such interaction but does not name it contributes to an additional injury by making their supervisee feel unacknowledged, gaslit, dismissed –or re-traumatized.
Validating the experience of the supervisee is essential, including by supervisors without personal experience on the receiving end of similar disparaging comments:
How can I protect somebody I supervise from something I don't fully understand? I can support them by listening and trusting their experience, as it is their life, not mine. (D5)
Indeed, the depiction of the dismissive response was considered more hurtful and ultimately more damaging than the initial racist injury: invisibility cancels out; it forces shut the experience. A point of consensus was that whenever invoking it directly, the focus must be on the person's offensive behaviors, not on the person as the offense, on racist acts, rather than on the person as a racist:
I'm not saying you are a racist, but that what you did was racist. I'm not judging you as the person you are, but your actions were racist and hurtful to the doctor I'm supervising.
(D6)
There was less uniformity regarding just when and how best to name racist acts directly with the aggressor: leaving things unsaid risks sanctioning behavior, normalizing it as either typical, expected, or an understandable reaction to stress. Such elisions could entrench jaundiced views not only about racism but around any of the prevailing isms or othering perceptions, including sexism, ableism, homophobia, or xenophobia.
3. Ownership: from individual to shared
Participants coincided on the need for a supervisor to take a direct stance, to "own" the interaction, and to lean into their protective responsibility. Nevertheless, they often felt left to their ingenuity, intuition, or interpersonal styles. Most yearned for policies and procedures to back their actions, for even imperfect guidelines setting realistic and appropriate boundaries. Involving intermediaries such as patient relations, security services, or an anonymous reporting system were all mentioned as steps in the right direction to support all parties not to feel dismissed or isolated.
In turn, some participants questioned what would be the optimal approach for an aggrieved trainee to take? Moreover, who would be best to share the hurtful event with? Bringing up the issue felt tiring and burdensome to some; raising it with a supervisor potentially fraught with danger, risking “being labeled unprofessional, which is just code for an individual of color who stands up for themselves." (S10) Some shared a resigned, even defeatist sentiment of "having to work in elitist institutions where this form of invalidation is a daily struggle," (S11) and where aggrieved trainees all too often come to accept generic and avoidant feedback from their supervisors. They deemed the medical enterprise a "retail business in which ‘the customer is always right,’" (F3) leaving trainees in the vulnerable position of feeling unprotected. Feeling alone when confronting experiences involving racism resulted in a sense that they could trust only certain peers or select supervisors for empathy or support, yet rarely for addressing the source grievance. Supervisors who had used their positionality in a constructive way to combat this type of behavior were cited as all-too-rare exemplars.
4. Involvement: from deferred (excusing) to cotemporaneous (including)
When is it reasonable to include the racially targeted individual when addressing the encounter with its offending source? In support of the inclusive approach, some participants saw a potential opportunity to model through visible actions, to have the trainee join in addressing the offense at its source. They hoped for supervisors with privilege to exemplify how addressing racism is work that should not fall entirely on those who are minoritized, as an opportunity to handle power differentials, to extend a learning opportunity to the trainee or the broader group of learners. However, the prevailing view supported a different approach: handling responsive actions at the moment with the offender –and at a separate time with the recipient. Several Black participants expressed doubt about not being harmed, let down, or abandoned once again, of entering into a clinical space
that is never a safe environment. We might be told it is; we might like to think it is. It may be safe for some, but for those of us who are marginalized, it's not. (S12)
Other participants preferred decoupling redress with the aggressor from repair with the aggrieved, giving trainees time and space for reflection, gathering outside support, and gaining agency over what could be helpful as a next step. By listening first and acting only later, a supervisor could point out that support comes not only at the moment but, just as importantly, between racist acts: “it’s for the long haul." (D7)
5. Stance: from protective to paternalistic
Supervisors can become unwittingly overprotective and paternalistic in their effort to address a racist injury effectively and support their charges. Centering the response on the needs of their trainee is the first way to avoid that potential trap. For example, a supervisor who “just waltzes in to save the day" (S13) can convey that only they can make things better and that the aggrieved trainee is not up to the task. Moreover, the stance can become transparently performative.
Supervisors are most welcome when "validating, affirming, and witnessing, rather than when postulating or lecturing." (D8) They are protective; they inquire openly and confidentially about what is needed at the time; whenever possible embed their support within a longer-standing relationship; they realize the limitations and the risks of providing "total protection, which they really cannot promise" (D9); they are protective, but do not veer into protectionism. It is an admittedly narrow strait to navigate:
How do I empower while being supportive at the same time? I want to be there for my trainee but don't want to be their rescuer, which could feel or come across as infantilizing. (S14)