“You Said, I Heard”: Speaking the Subtext in Interracial Conversations

Abstract

Medical trainees who come from racial and ethnic minority communities and/or from economically and educationally disadvantaged backgrounds face unique external and internalized challenges that may lead to academic difficulties. Given there are still few faculty members from racial and ethnic minority communities, supervision is likely to be cross-racial. Using illustrative cases and their own personal experience as supervisor and student, the authors, the director of the Social Stress and Health Research Unit in the Department of Psychology of St. John’s University and a PhD candidate in this program, review what is known about the dynamics of racism, its effects on mood, the pathways through which racism may affect academic performance. In particular, they discuss what is known about interracial communication styles, race-based stereotypes, and formation of schemas about self and others. They suggest strategies to combat the formation of judgments of which we are not even aware, to recognize stereotype threat and confirmation bias, and to address these issues within student and teacher relationships.

The ideas for this chapter developed as the first author was working on projects funded by R01HL068590. The authors would like to thank Susan Kittenplan of Kittenplan LLC for introducing us to the concept of “Speaking the subtext”.

Appendices

Appendix A: Putting It All Together (A Rubric for Analyzing and Remediating Difficulties and Presenting Problems)

There can be many examples of presenting problems that may be influenced by race-based maltreatment (e.g., the student does not complete assignments, the student does not ask for guidance with difficult problems, the student appears uncomfortable in conversation or avoids communication with the faculty, or the student’s behavior is not professional (i.e., too informal/too formal, too inhibited/too aggressive, unprepared/too much preparation and detail, cannot acknowledge mistakes/over-apologizes)).

Provide a Clear Description of the Difficulty (Identifying Signs and Symptoms)

It can be most helpful to formulate the problem in specific measurable terms (e.g., “You are 3 weeks behind in handing in this report and have not incorporated the suggestions we made an earlier draft.” or “You don’t seem to make eye contact or volunteer information when we are discussing cases.” If appropriate, make explicit the point that you are not making comments about the student’s overall competence, but are concerned about this specific piece of behavior.

Identify Risk Factors

• Proactively identify stereotype concerns: Think about the stereotypes that might be communicated by the particular feedback (e.g., Are you communicating about the student’s trustworthiness, intelligence, class?). Can you clarify that you are speaking about a specific issue and not making general statements about the individual?

• Pay attention to nonverbal expressions of distress: Watch for signs of avoidance or agitation and scan for evidence of depression.

• Gather information about the history of barriers and resources: What are the cultural messages communicated about the student’s racial or ethnic group? What kinds of environmental supports does this student have? What kinds of social supports does this student have? Is there a reason to suspect that the student is concerned about or does not have experience with social rules or communication or writing rules? How do the resources available and the perceived or real barriers change the amount of motivation needed?

Interventions

Consider speaking or writing the subtext to clarify the messages you are giving and receiving. Write down the sentences you spoke when you gave feedback. Ask the student to provide information about their perceptions of the sentences and the emotional meaning of the sentences to the student. You can ask them about their professional identity and their concerns about stereotype threat. You might inquire about their beliefs about independence or their fears of being perceived as ignorant or incompetent if they ask for assistance.

• Provide models: Models can help students make improvements independently. If students are worried about not understanding the subtle details of communication, provide models of writing. If students are not expressing themselves clearly or handling themselves professionally, try role playing exercises. Examples of exercises are included in the next section.

• Anticipate potential barriers: Ask if the student is facing any of the common barriers to academic achievement (i.e., confusion about writing, outside demands, family responsibilities).

• Speak the subtext yourself: The faculty can provide explicit comments on their own concerns about these conversations, communicating their stereotype threat concerns. It can be helpful for faculty to discuss their worries about the costs and benefits of having personal conversations with students. You can address the nature of the “commitment” students can expect from faculty.

Appendix B: Applying the Knowledge: Remediation Ideas and Exercises

Here are some exercises to increase understanding of the effects of cultural, institutional, and interpersonal racism. In each exercise we are attempting to increase the ability to speak the subtext—to communicate the ways in which social contexts and interpersonal interactions can undermine professional development.

5.1 Exercises to Increase Understanding of Cultural Stereotypes

Discussing the stereotypes that are frequently communicated in the media can help students and faculty become aware of the ways their beliefs may have been influenced by cultural communications.

In Table 8.1 we provided examples from our own experience of some common stereotypes about African Americans, and that KLJP internalized. Awareness of stereotypes for other racial and ethnic groups (not to mention other groups of diversity) may help you anticipate when students might have concerns about implicit bias and take the time to clarify your feedback, increasing its detail and specificity and avoiding more global judgments. If you see a student become uneasy (i.e., avoid eye contact, provide brief answers, or become overtly agitated), you can ask questions about their concerns about implicit stereotyping.

To increase awareness of stereotypes, students and faculty members can identify different movies or TV shows that portray stereotypes and others that present alternative models. It can be useful for faculty and students to hear how different people from different ethnic or racial groups perceive the characters portrayed.

5.2 Exercises to Understand the Effects of Institutional Racism/Residential Segregation on Access to Resources

Medicine can be a dynastic profession (i.e., there are often many generations of physicians in a family). But students who are the first in their family to go to college or graduate school may not have these resources available. Asking or finding out about educational and opportunities and informal support networks can be useful. You can ask: “Who do you turn to rehearse tough conversations with faculty or patients—someone who can give you the inside scoop?”

Some students may not have someone to explain tough course material or difficult clinical situations. For those students, it can be valuable to provide a low-stakes mentor—someone who can give them “behind the scenes” advice and information. This person can provide the knowledge and confidence that can bridge the gap between the student and a high-stakes faculty (i.e., a clerkship faculty). More senior students or program administrators can sometimes serve as “low-stakes” support.

5.3 Exercises to Improve Recognition of the Effects of Racism on Motivation

Think about the neighborhoods you lived in and the schools you attended when you were growing up. What cultural messages did you receive about the characteristics associated with you and your ethnic group? Did those messages increase or decrease your motivation to work hard? What physical and social resources were available that helped you feel successful (i.e., what kinds of strength did you gain from your family, neighbors, or relatives or your teachers, mentors, or spiritual leaders?) What kinds of opportunities to develop new skills were available in your early years (i.e., after-school programs, recreation areas, enrichment programs)? Did the resources help you think you could succeed? Did they make it easier to be motivated to try? On the other hand, what obstacles slowed down your ability to succeed (e.g., interpersonal conflict, lack of resources)? How much motivation did you need to overcome these barriers? Most people can “turn on the steam” or find the motivation to work intensely for a short period (i.e., sprint to the finish line of a course), but it is much harder if extra motivation is needed for longer periods of time.

5.4 Exercises to Improve Recognition of Subtle Interpersonal Maltreatment

We all communicate much more information through our nonverbal behavior than through the content of our words. Our nonverbal behavior may be communicating message we do not realize or intend. Research from social psychologists indicates that African Americans can make reasonably accurate judgments about someone’s implicit racial bias, based on a 30 s brief of routine conversation. Increasing awareness of the emotional message we communicate can help us improve interpersonal communication.

One exercise includes brief role plays to help students identify the emotions communicated by even minor variations in nonverbal behavior. This exercise is an adaptation of work we have done in different employee groups [70, 71]. It can be especially helpful if students first engage in the exercise with no faculty present. Then when they are more familiar with the process, students can repeat the exercises with both faculty and students participating.

Participants sit in a circle. The assignment is for each person to take a turn approaching a “faculty” (i.e., initially a student playing a faculty) who sits in the center of the circle. One at a time students take turns asking the “faculty” a single question (e.g., “How or when do I …. (some procedure)?). Each student repeats the approach and the question three or four times. The first time the student asks in his or her normal manner. Then group members suggest minor changes to either body language (e.g., move more quickly, raise your shoulders, furrow your brow, avoid eye contact) or tone of voice (e.g., speak more softly (loudly), speak more quickly/slowly, clip or emphasize consonants). Group members make recommendations about body language or tone of voice rather than how they want the emotional message to change (i.e., they say “raise your shoulder” rather than “look defensive”). This helps keep the focus on deciding emotional cues and recognizing the ways small but significant changes in body language change emotional tone.

Each time the student asks the question, group members give feedback on the degree to which the student is communicating confidence vs. fear, openness vs. defensiveness, and respect vs. disrespect or arrogance.

When a faculty member joins the group, the faculty member can role play giving one sentence worth of feedback (i.e., essentially “Don’t do that, do this.”) to a student sitting in the center of the circle. They repeat this feedback with modifications of body language and tone of voice. Students and other faculty can give feedback about the emotional communication of the faculty (approachable (open and interested) vs. rejecting (closed and annoyed), respectful vs. condescending or patronizing, patient vs. impatient).

At the end of the exercise, participants can identify different specific pieces of body language and tone (i.e., muscle tension or forceful consonants) that change the communication of emotion.

This exercise can be particularly helpful for students who are foreign-born or from cultures, which have very different rules about the ways in which women vs. men should communicate respect. For example, in some cultures women sometimes communicate respect by speaking softly, lowering their head slightly, keeping distance from the other person, and keeping their gestures close to their body. However, these same nonverbal behaviors can communicate subservience to people of other cultures and therefore undermine authority.

5.5 Writing the Subtext

You can use a chart that has columns we present above (“You said, I heard” stereotypes). You might want to add another column in which the faculty clarifies his or her intent and establishes a more effective method of communicating his or her ideas.

A more informal way is also possible. For example, when critiquing academic work, it is also possible to say something like “Teachers and students often misunderstand each other. I want to make sure that we are on the same page. The feedback I am giving you is about your specific paper at this point in time. I am not communicating anything more general about you as a person. And I want to make sure that we can discuss any concerns you might have that I am acting on any biases I might have (about your gender or age or racial or ethnic group).”

Asking the student to write out the comments he/she heard and his or her interpretation of the subtext can help identify the barriers to performance. The upside of this strategy is that it is extremely clear and provides the student with an opportunity to take the time to write out his/her thoughts. The downside is that it is scary for mentors to see the student’s anger and distress. These exercises can also make the student nervous about anonymous retaliation. Therefore, this activity requires a fair amount of trust. However, the faculty member opens the door and asks the questions, there can be a change in the ability to remediate future difficulties.

For KLJP and EB, these conversations were simultaneously very painful and also very interesting and moving. Ultimately, they permitted us to be more completely ourselves and strengthened both our individual identities and the mentor–mentee relationship.

5.6 Writing Remediation Exercises

We use two strategies to improve writing in students, both of which are time-consuming. When we are preparing papers for publication or presentation (and every word has to be correct), we sit together and read aloud. The papers are edited jointly and in real time. This provides an opportunity to articulate the rules of grammar or to describe the nuances of choosing just the right word. If everyone is taking turns reading and writing (and listening), many of the subtle features of general writing and professional communication, in particular, are communicated naturally (e.g., this sentence would be clearer if we followed the rule of parallel construction).

Another strategy involves sharing three sample papers (or case presentations) from different students (with the names removed) and allowing students to see models and identify areas in need of improvement. Students often believe that they are the only person having any difficulties writing, and they often do not have good models for the specific type of writing they need to accomplish. Providing models (with comments about the strengths and weakness of the work) can help normalize the experience of needing help and underscore how much time and effort it takes to develop clear prose.

Template for “You said, I heard” exercises

“You said….” the student’s recollection of the faculty member’s feedback or comments	“I heard…” what the feedback meant to the student	Any stereotypes evoked by the comments or feedback	What is the intent of the feedback that is given to the student
–	–	–	–
–	–	–	–
–	–	–	–
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