Medical Schools Are Failing Minority Students

Below is a guest piece by Dr. Chase Anderson, resident physician in psychiatry at The Massachusetts General Hospital and McLean Hospital. He is an incoming child and adolescent psychiatry fellow at UCSF.

As a society, we imagine that hospitals are places where healing occurs. Being a doctor remains one of the most illustrious careers that a person can aspire to. In those supposedly hallowed halls, cancer is sent into remission. People with suicidal ideation are supported until their plans to harm themselves remit. Those experiencing a heart attack are given medications that can save their lives. Truly beautiful stories of recovery are told about those aforementioned halls.

But, is that dream of safety and healing true for everyone? Is the hospital truly a safe space for all who work there? What if those halls hide a terrible not-so-secret secret?

A JAMA Internal Medicine paper seeks to shine a light on one of those darker sides of medicine. In their article, “Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation” (Hill et al.) sought to examine just how frequent episodes of mistreatment are. Their group peeled back a little more of the curtain that shrouds how damaging medical training can be to the psyche of medical students.

When a medical student graduates, they fill out a survey known as the Graduation Questionnaire. Within the questionnaire, there are questions about mistreatment, which includes verbal abuse, discrimination, and sexual harassment. Hill’s group wanted to examine this data to answer the following question: Is there an association between the prevalence of medical student mistreatment and sexual orientation, race/ethnicity, and gender?

To that end, the group looked at the Graduation Questionnaire responses from 2016 and 2017. On the questionnaire, demographics were as follows: male or female for sex; white, underrepresented minority, Asian, or multiracial for race/ethnicity; lesbian, gay, bisexual, or heterosexual for sexual orientation. One was deemed to be an underrepresented minority if they were Alaska Native, Native Hawaiian, Pacific Islander, Spanish, Latino, Hispanic, African-American, black, American Indian. People who identified with more than one race were categorized as multiracial.

With regard to discriminatory events themselves, Hill’s team narrowed their focus to specific behaviors that they called “negative behaviors.” Negative behaviors included being humiliated, threatened with physical harm, denied opportunities for training, lower grades/evaluations, being subject to offensive remarks or names. In essence, behaviors that lead to an unsafe learning environment. Sequela thought to arise from such an environment have been well documented: higher levels of cynicism, burnout, alcohol abuse, and depression.

What they discovered was shocking, yet, sadly, not unexpected. Of the 27,504 students included in the final group studied, over 35 percent of students suffered at least one type of mistreatment.

When this was broken down by sex, female students experienced more discrimination than men, which included unwanted sexual advances and public humiliation. Women experienced receiving lower grades due to gender, were denied training opportunities, and many of them reported two or more types of mistreatment. These were all at a higher prevalence than their male counterparts. This data included females experiencing sexist remarks (24.3 percent versus 3.4 percent), and reporting two or more types of mistreatment (17.8 percent versus 7.0 percent), among other such statistics.

Such statistics were also seen to hold true for racial/ethnic minorities and LGB students as well when compared to white colleagues and straight colleagues, respectively. One example of this: Hill’s group found that 43 percent of LGB students stated they had experienced an episode of mistreatment, while 23.6 percent of heterosexual students stated the same.

Notably, this cohort is one gleaned from a national database. This means that it is one of the largest studies of this kind to date, which is all the more concerning given the overarching takeaway:

It is often dangerous to be a minority in medicine.

In too many ways the playing field is not level for minorities in medicine.

Not only were people of minority status noted to face higher levels of discrimination, but Hill’s team also noted the negative power of intersectionality in medicine. Namely, if one was a female medical student and an ethnic/racial minority, they experienced higher levels of discrimination than if they identified with only one of those categories. Other papers have spoken to this “double minority status,” and the additive effects of minority stress over the lifetime of a person in such toxic milieus.

Bias Essential Reads

The Impact of Puberty on Racial Bias Against Black Children

Navigating Cognitive Minefields

The study does note limitations. There is the possibility that we may not be capturing the extent of mistreatment, given that some students may have departed medical school before graduating due to these negative behaviors. The questionnaire also does not have data on transgender people, a historically discriminated against group. Underrepresented minorities were also placed into a larger category of URM without a breakdown by specific race.

These behaviors for anyone are harmful. This data points out, however, that those who identify as minorities inside of medicine bear a higher burden of these instances. And these comments and negative behaviors often come from all sides: patients, staff, fellow medical students, residents, and attendings. Hill’s paper says it best when they point to other literature on worsened mental and physical health, worsened grades, and “lower academic motivation and persistence” of students who experience these events.

What do we do?

Hill’s group eloquently speaks to ways in which we can help medical students who identify with one or more minority status. They mention different types of training surrounding implicit bias, safeguarding the environment for minority medical students, policies to address issues of discrimination, the creation of a chief wellness officer, among other ideas. One of the greatest facets that the article brings to the table is building continued awareness that these issues are far more common than one might expect.

Although data paint a pretty bleak picture it certainly provides fodder for conversation. It states boldly and plainly that medical schools and hospitals have work to do. Especially if we want to reach the day where trainees are truly safe to learn and grow as physicians.

This African-American, gay psychiatry resident will certainly be looking forward to when that day arrives.

Chase T.M. Anderson, MD, MS, is a resident physician in psychiatry at The Massachusetts General Hospital and McLean Hospital.