Struggling with Discrimination: An Intersectional Exploration of Why Unequal Social Relations Persist in Residency Training Programs.

Introduction: Although postgraduate medical education programs in North America have committed to addressing equity, diversity, and inclusion (EDI) issues, learning environment inequities persist and negatively impact learning outcomes. We conducted an exploratory qualitative study to identify mechanisms contributing to ongoing discrimination experiences. Methods: We took an intercategorical intersectional approach to conduct a qualitative thematic analysis that focused on unequal social relations as the unit of analysis. Participants were recruited from paediatrics, neurosurgery, and plastic surgery residency training programs. We performed multi-level inductive and deductive coding of semi-structured interviews informed by intersectionality and systemic and aversive racism. Results: 13 participants were interviewed. Participants identified their social identities as marginalized or dominant, and reported intersectional exclusion experiences related to the former that disadvantaged them compared to their peers. Persistent unequal social relations could be mechanistically accounted for by aversive or systemic racism regardless of intersectional identities. Aversive discrimination appeared through performative EDI commitments, microaggressions, and social exclusion. Systemic discrimination contributed to exclusion stemming from the operationalization of cultural norms such as scheduling, social events, and censorship of taboo topics. Participants described variably successful compensatory strategies to overcome their marginalization. Discussion: Systemic and aversive discrimination contribute to reproducing unequal social relations. Evidence-based approaches exist to address these mechanisms and make learning environments fairer.