Racism in medical schools influences students’ decision to work with minority patients, communities
Racism in medical schools influences the decision of a student whether or not to work with minority patients or practice in underserved communities. When a student’s explicit racial bias becomes more negative during medical school, they are less likely to practice in a minority or underserved community, according to a study of 3,756 medical students across 49 US medical schools in their first and final semesters.
Observing microaggressions - verbal, behavioral, or environmental insult or humiliation - against minority students can make students lose interest in practicing in underserved areas, shows study evidence. The team found that racism at the structural or cultural level could reinforce a belief in the “social hierarchy” and dissuade students from a career focused on caring for those perceived to be lower in that hierarchy.
“The key conclusion from the study was that elements of medical school curricula, culture, and students’ interpersonal experiences might all contribute to a student’s decision about where to practice medicine. There are severe, and worsening shortages of physicians practicing in underserved areas, and this study provides evidence that medical schools may help address that trend by paying attention to the values and norms that are communicated to their students,” first author Dr. Sean Phelan, a Mayo Clinic health sciences researcher, told MEA WorldWide (MEAWW).
According to the findings, published in Academic Medicine, individual student attitudes and behaviors tended to change over four years of medical school, and there were critical factors that predicted whether students changed their minds on wanting to work in an underserved area or a primarily minority community.
The researchers found that school curricula and policies can create an unintended, structural type of racism if they lack content on cultural awareness, racial disparities, and bias. They also found that the culture and climate of medical schools, including the behaviors that are “role-modeled and considered acceptable or normative,” can have a significant influence on students’ career decisions. For example, two survey questions measured faculty role-modeling: “I have witnessed racial insensitivity from faculty” and “How often have you heard professors or residents make negative comments about black patients?”
“School culture and climate, including behaviors exhibited by faculty and attending physicians, represent a hidden curriculum on acceptable or normal ways to interact. Several studies have demonstrated the importance of the hidden curriculum in medical education, and these findings support the notion that students’ decisions may be influenced by the climate of the medical school and the behaviors they observe and seek to emulate. For example, observing microaggressions against minority students and feeling less encouraged to interact with people from different cultures and racial groups were associated with lost interest in practicing in underserved areas,” says the study.
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The paper is the latest to present findings from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) - conducted by Mayo Clinic’s research group on equity and inclusion in healthcare, in collaboration with Yale University and the University of Minnesota.
Dr. Phelan further explains that in another paper from this study - led by Dr. Sarah E. Burke from Syracuse University - they found that role modeling by instructors and faculty members at medical schools influenced students’ attitude changes. “Students who were exposed to more frequent instructor negative comments or jokes about racial minorities had more negative racial attitudes themselves after controlling for their racial bias at the beginning of medical school. In that same study, we found that students who had more contact with minority students, faculty, staff, and patients during medical school had the greatest positive change in their racial attitudes,” he says.
In their current study, the researchers found that students’ negative racial attitudes at matriculation (first year) were associated with decreased intention to practice with underserved or minority populations at graduation, while students who had more interactions with black students, faculty and allied health staff, and considered those interactions favorable, were more likely to choose to practice in a black community.
“The factors (that discourage students from practicing in the minority/underserved communities) varied according to whether students came into medical school wanting to eventually practice in an underserved or minority community or not. But, in general, when students’ explicit attitudes about racial minorities became more negative during medical school, they were less likely to practice in a minority or underserved community. Students became more likely to practice in one of these communities if they completed curriculum in minority health or health equity or took part in a service-learning experience, or if they felt that their school was committed to diversity, had more opportunities to interact with minority students, faculty, and staff, or if their school had an environment that supported them to become more skilled at developing positive relationships with minority patients,” Dr. Phelan told MEAWW.
The analysis
Students were asked two questions: “Do you plan to locate your practice in an underserved area?” and “Do you plan to work primarily with racial or ethnic minority patients?” At baseline, 846 students (22.8% of the 3,700 students who answered the question) indicated their intention to work in an underserved area, and 603 (of 3,697, 16.3%) indicated their intention to work with minority populations; 2,197 (of 3,700, 59.3%) and 1,997 (of 3,697, 54.0%) were undecided, respectively.
At follow-up, 1,374 students (of 2,197, 62.5%) remained undecided about working in an underserved area, and 1,197 (of 1,997, 59.9%) remained undecided about working with minority populations.
Additionally, 1,104 students (of 3,756, 29.4%) gained or maintained their intention to work in an underserved area, and 1,183 (of 3,756, 31.5%) gained or maintained their intention to work with minority populations.
However, 1,161 students (of 3,756, 30.9%) lost their intention or maintained their lack of intention to work in an underserved area, and 1,247 (of 3,756, 33.2%) lost their intention or maintained their lack of intention to work with minority populations.
“Gaining interest in both working in an underserved area and caring primarily for minority patients was associated with taking part in a seminar on minority health, the medical school’s learning orientation toward interracial interactions and the number of interactions students had with black students, faculty, and staff. Service-learning and the students’ perception that their school was committed to diversity were associated with gaining interest in working in an underserved area. More negative fourth-year explicit racial attitudes and increased medical authoritarianism were associated with losing or maintaining no interest in providing care in an underserved area or for minority patients,” says the analysis.
However, among students who initially intended to work with minority populations, those who witnessed examples of discrimination in medical school were more likely to stay committed to that path.
“Interestingly, the percentage of students at each medical school, who were members of underrepresented minority groups, was associated with students maintaining interest in caring primarily for minority patients as well as with their losing interest in working in an underserved area. A tenser interracial climate at the medical school and more frequent experiences of race-based microaggressions reported by racial minority students were associated with gained interest in caring for minority patients. These associations might stem from increased awareness of racial discrimination, which could drive both the likelihood of students noticing tension and their interest in working with minority patients,” it says.
Researchers suggest intervention strategies
Stating that structural racism is deeply embedded in all areas of society, and medical education is no exception, researchers recommend strategies to identify and eliminate structural racism, and its manifestations in medical school. They suggest that, within medical education, the types of courses that medical schools require and the information that they prioritize for training new physicians can critically shape students’ interest in practicing in underserved areas. “The findings suggest that medical education leaders can take action to affect students' decisions to work with underserved populations,” the study says.
They recommend intervention strategies such as seminars and curricula in minority health and health disparities, service learning, strengthening communication skills training to build students’ competence in positive relationship building with minority patients, fostering collaboration among diverse students, and facilitating discussions of racial inequity where students are encouraged to learn from each other’s experiences.
“We hope to raise awareness in medical school decision-makers that the courses that are required or available and the values and norms within a school’s culture communicate to students what is important and how a doctor behaves. By using a structural racism framework to examine the curriculum and the student experience, we may identify biases or gaps that influence students’ values and attitudes, as well as where and how they choose to practice medicine,” Dr. Phelan told MEAWW.