Creating Space for All at the Beside: Centering Diversity in Medical Education Research

Family-centered rounding (FCR) has been a staple of hospital medicine for more than 2 decades and is often a preferred rounding method for education.1 This method of multidisciplinary rounding, conducted in the patient room to promote family engagement and shared decision-making, has demonstrated positive outcomes with measures such as improved family satisfaction and patient safety.2 However, little research has been done on resident psychological safety and familial trust of residents during FCR, and this study takes initial steps to fill this gap.Bhatia, Yan, and Seltz present important findings that describe perspectives on FCR from the viewpoints of both residents and families, specifically focusing on psychological safety of residents and family members’ trust in the medical team.3 This qualitative study used grounded theory methodology in the conduction of focus groups and interviews including 25 pediatric residents and 15 family members of hospitalized children. Data analysis revealed 6 themes: (1) psychological safety in asking questions/being “wrong,” (2) worry about losing trust from families and team, (3) supervisor support of autonomy, (4) family understanding of the value of experiential learning, (5) family trust related to interpersonal skills, and (6) team dynamics/expectations. A central finding was that residents experience both safe and unsafe FCR, with psychological safety improved by supervisor support and learner autonomy. Additionally, family trust of residents was driven primarily by interpersonal skills, while resident knowledge gaps or questioning did not negatively impact trust among participants.One of the primary strengths of this study is its inclusion of and focus on the perspectives of family members—an often-underrepresented voice in the literature surrounding FCR. To our knowledge, this is the first qualitative study to explore the factors that impact families’ trust of residents during FCR, offering critical insight into how care teams are experienced by those most directly impacted by their decisions. By centering family narratives, the authors illuminate nuanced dynamics that may not be visible to clinicians or trainees. Further, they advance our understanding of how communication, transparency, and team hierarchy are interpreted by families. Crucially, this study challenges the notion that trainees must be “right” in front of families to earn their trust, a belief that may deter trainees and care teams from honest and vulnerable participation during FCR. This perspective is essential for guiding meaningful improvements in medical education and patient- and family-centered care practices.As we consider how these valuable findings might be applied to other contexts, we must also consider the diversity of study participants and highlight the necessity of working toward recruiting voices of groups that have been historically marginalized. The authors highlight the limitation of the narrow demographics of the study participants, drawing attention to an important direction for future research. Of the residents included in the study, 92% identified as female and 88% as white. Similarly, among the family members included in the study, 87% identified as female, 73% identified as white, 80% had at least a college education, and 93% reported that their child did not have a chronic illness. As we consider the transferability of these results to other contexts, we must wrestle with how these demographic factors might impact psychological safety and trust. For residents, experiences of psychological safety can vary on multiple axes of identity, including race and ethnicity4 and gender.5 Similarly, experiences of families of hospitalized children may vary based on race, level of education, primary language, and chronicity of their child’s illness.6,7 Underrepresentation in research has been studied in depth in the setting of clinical trials; although relatively underexplored in the medical education research setting, it remains valuable to consider how conversations from the clinical research space might apply here.Disparate recruitment of participants occurs in numerous types of research, including observational studies, basic and translational research, and psychosocial research, which limits generalizability of clinical findings and further exacerbates health disparities in the populations that are underrepresented in or excluded from studies.8 Within clinical research, underrepresentation is particularly prevalent in smaller, single-center studies.9 Previous research has described barriers to research participation for racial and ethnic minoritized groups, including lack of access to information about opportunities, mistrust of institutions and researchers, uncertainty of participation outcomes, and logistical challenges including financial constraints, language barriers, and insufficient transportation or time of parents/caregivers.8,10The responsibility to overcome these barriers and to pursue representative study groups ultimately lies with those conducting research. A scoping review of recruitment and retention of rural pediatric research participants identified inadequate staff and resources as commonly cited barriers; conversely, it also revealed contacts/reminders, community engagement, relationship building, consideration of participant logistics, and incentives as facilitating factors.10 Similarly, an interview-based study with pediatric clinical trial research staff highlighted 5 areas of opportunity across the research continuum to improve the diversity of our research participant recruitment: access to clinical care, distribution of research efforts and associated opportunity, relationship building, informed consent, and logistical burdens of participation.11 This study by Weiss et al provides a useful framework for identifying opportunities for improvement, although notably, the study itself primarily includes white, young, female, and highly educated study participants.The goals of increasing diversity of clinical trials include learning and building trust, promoting fairness, and generating knowledge.12 Medical education research has some notable differences from clinical research, including the higher prevalence of qualitative methodologies and often smaller sample sizes. However, there likely remain learnings that can be drawn from this framework. Earning and building the trust of our trainees and patients’ families is critical as we make a case for building systems with everyone’s best interest at heart. From the perspective of promoting fairness, research inclusive of diverse trainee participants helps ensure that we are building educational frameworks upon data that are representative of all our trainees; similarly, research inclusive of diverse patient participants ensures our residents are being trained to care for all patients and families. Finally, diversity in medical education research is critical to ensuring we are generating robust and nuanced knowledge within a rapidly evolving, complex field.As we consider the challenges of increasing diversity in research, we must also wrestle with why this is challenging. In part, decreased diversity in medical education research may reflect a persistent lack of diversity among trainees on some axes of identity.13 We cannot include participants who are not present, which highlights the need to continue to investigate why medical education continues to struggle with trainee diversity. The work of ensuring that we are deliberately building inclusive systems of medical education requires that they be informed by inclusive data. Promoting psychological safety among learners and families on rounds is paramount in creating a health care environment that is both conducive to high-quality, evidence-based care for patients and also an effective learning environment for trainees. Bhatia, Yan, and Seltz begin to tackle this expansive topic and offer helpful insights into what this ideal environment might look like. Future steps to further improve understanding of family-centered rounds would be to diversify the context in which FCR is studied, including with families with diverse identities, who speak languages other than English, or who have children with medical complexity as well as with trainees of diverse backgrounds and identities.This study serves as a starting point on the road to understanding psychological safety in FCR, with the goal of future research exploring how this rich topic applies to all our learners and families. It not only pushes us to envision a rounding environment that is psychologically safe for trainees and families alike but also opens a dialogue about how we can ensure that we are investigating and prioritizing psychological safety for all trainees and families, including those historically underrepresented in research. Although representation within medical education research has not been as deeply explored compared with the clinical research setting, attention to similar patterns of underrepresentation remain critical to broadening the application and inclusivity of research findings. As such, the importance of studies like this one that open a dialogue about including the voices of all those involved in medical education and the health care system cannot be overstated.