Odom, Kara L. MD, MPH; Roberts, Laura Morgan PhD; Johnson, Rachel L. MD, PhD; Cooper, Lisa A. MD, MPH
As the population of the United States becomes more ethnically diverse, and as a growing body of research links diversity in the physician workforce to improving health care quality and access for racial and ethnic minorities, medical educators and administrators are challenged to develop effective programs for recruiting and retaining underrepresented minority (URM) medical students.1–4 Despite many aggressive initiatives by the Association of American Medical Colleges (AAMC) to increase the numbers of URMs attending medical school (i.e., Project 3,000 × 2000), the success of such programs is hindered by difficulties that URM students enrolled in medical school face on their career paths through graduation and later in residency and faculty positions.5–7 URM medical students face the unique challenge of working with professors, attending physicians, residents, and colleagues whose cultural backgrounds are very different from their own. Moreover, URM medical students have reported stresses and challenges associated with learning in what they perceive to be a prejudiced and hostile environment.8–9
Medical educators and administrators need a plan of action and specific programmatic recruitment and retention strategies to encourage minority students to enter health careers for the benefit of all patient populations. The ability of pipeline programs to achieve desired goals (i.e., increasing the number of ethnic minority physicians with successful careers) may be enhanced by developing a better understanding of the barriers faced by minority students upon their matriculation in medical school and by identifying the factors that promote success. Much of the current research on the quality of medical students’ experiences is presented from the perspective of medical school or academic health center administration.10–15 It is unclear whether the assumptions made by administrators, researchers, and educators regarding minority students’ opportunities for and obstacles to professional success in medical school are substantiated by students’ experiences. Our study questions were as follows: (1) What factors have facilitated URM medical students’ personal and professional success? (2) What challenges have inhibited their personal and professional success?
To explore these questions, we conducted six focus group discussions with medical students located in Philadelphia, Pa; Kansas City, Mo; Baltimore, Md; Miami, Fla; New York, NY; and Los Angeles, Calif, in 2002 and 2003. Focus group participants are usually selected to generate a wide range of views, experiences, and opinions, thereby providing useful information for hypothesis generation for future research.16 Additionally, conducting focus groups is particularly effective in providing in-depth information about what people think or feel about an issue and can be a useful method to guide development of new programs.17 We chose focus groups over individual in-depth interviews because we believed minority students would have some shared experiences and feel empowered to speak in the presence of their peers. We asked minority medical students to characterize their own personal goals, experiences, and needs with regard to medical school and their future professional practice. This approach enabled us to discover opportunities for and obstacles to success from students’ perspectives.
Eligible participants were medical student members of the Student National Medical Association (SNMA). The SNMA is a nonprofit 501c(3) corporation and is the oldest and largest medical student organization dedicated to the education of minority medical and prehealth students. Established in 1964 by medical students at Howard University and Meharry Medical College, the SNMA claims more than 40 years of service to underserved communities. As of June 2003, the concluding year of this study, SNMA had a membership of 5,323 and over 200 chapters, with each chapter ranging in size from 2 to 200 members. The membership at that time was 66% female and 69% African American/black, 6% Latino, and 4% Asian.
We asked regional representatives from 6 of the 10 existing regions of the SNMA to help us recruit participants for this study by distributing flyers to students from various institutions. In each instance, we asked the representative to make special attempts to include students from all four years of medical school and to recruit equal numbers of men and women, but no specific efforts were made to recruit participants according to race or ethnicity. To be eligible for the focus groups, participants had to be current medical students, over 18 years of age, and able to give informed consent. Two of the authors were members and officers of the SNMA during the study period, but otherwise did not have a particular relationship to study participants. The institutional review boards at Harvard University and Johns Hopkins University Bloomberg School of Public Health approved the study.
Conduct of focus group sessions
Before conducting the focus group sessions, two facilitators (KLO, RLJ) discussed the goals of the project with the principal investigator (LMR) and reviewed the literature regarding minority medical student experiences, support programs, and obstacles to success. During each session, the two facilitators (one to moderate the discussion and the other to take notes and to assure that tape recorders were working and surveys and consent forms were completed by participants) informed participants that they would take part in an informal conversation for approximately two hours. They told participants that the aim of the study was to learn about commonly held views and individual perspectives of URM medical students. Participants were notified that the discussion was confidential and should not be discussed with others outside of the focus group. They were also informed that they could withdraw from the focus group at any time and were under no obligation to answer questions that they found to be too personal or sensitive. Written consent was obtained from each participant. Participants received a discount to the SNMA national convention as compensation for their time.
Facilitators asked students a series of open-ended questions about their experiences in medical school. In addition, they asked students follow-up questions to elicit more detail about facilitators of and barriers to success in medical school and to identify potential areas that may be targeted for recruitment and retention programs. The four key focus group questions were: (1) As each of you reflect on your medical school experience, name the one thing that you would say has most facilitated your success and the one thing that has most inhibited your success, (2) How do you define success (currently and in the future)? (3) Based on the definitions of success, what types of support systems and opportunities have facilitated your success or make achieving success easier? and (4) Based on the definitions of success generated by the group, what types of things have, or might in future, inhibit your success or make achieving success more difficult? Additional probes were asked in each of these categories as summarized in Appendix 1. At the end of the session, participants completed a brief questionnaire that included individual demographic and socioeconomic characteristics and approximate school demographics.
Data analysis and development of taxonomy
Audiotapes of the focus group discussions were transcribed verbatim, and identifying information was replaced with numeric participant codes. For the data analysis phase, two investigators (KLO, LMR) independently read the transcripts in their entirety, marking the comments that they thought represented discrete thoughts or themes using concepts of grounded theory.18 Comments were separated into domains with thematic labels derived from the actual words of the focus group participants. We used ATLAS.ti qualitative software (ATLAS.ti Inc., Cologne, Germany) to facilitate data management and analyses. A third investigator (LAC) adjudicated differences in domain assignment between the first two reviewers. Domains and comments underwent independent second review for relevancy and consistency by a fourth investigator (RLJ). This process resulted in the consolidation of some categories and the separation of others into related subdomains. Agreement between first and second stage reviewers was high at 99%. After second-stage adjudication, all reviewers agreed on the final taxonomy. Reviewers represented expertise in medicine, qualitative research, health and social behavior, and organizational behavior.16,19
We successfully scheduled six focus groups with an average of seven participants (range 5–10) individuals, for a total of 43 medical students: eight (19%) fourth years; 17 (39%) third years; 14 (33%) second years; and four (9%) first years. Thirty-eight (88%) of the students were of black/African descent (with 18% indicating Caribbean descent and 12% indicating continental African descent), four (10%) were Hispanic, and one (2%) was an Asian/Pacific Islander. Thirty-one (72%) were women. Students attended both private (55%) and public (45%) institutions. Characteristics of the focus group participants are shown in Table 1.
Focus group taxonomy
Content analysis of all six focus groups yielded 748 distinct comments, which we grouped into three broad categories: definitions of success, facilitators, and inhibitors. Comments could be included in more than one category, but the number of double-coded comments was less than 10%. The category “success” had seven domains: financial, professional/academic, happiness, identity, self-determination, balance, and service. The category “facilitators” was made up of four domains: scholarships, support, professional exposure, and personal characteristics. The category “inhibitors” had six domains: financial, lack of support, testing, self-limitation, cultural representation, and discrimination. This paper focuses on the facilitators and inhibitors to success described by minority medical students; however, to provide context for this discussion, below, we briefly describe the definitions of success provided by the minority students in our focus groups. We then present detailed descriptions of facilitators and inhibitors and their respective domains. Sample comments from each domain and subdomain are presented in Lists 1 and 2, respectively.
Definitions of success
Before asking about barriers and facilitators to success, we first sought to clarify how minority students defined current and future success. This question was important given that much of the previous research on this population has focused on academic achievement outcomes such as medical school acceptance, performance, and residency placement. Thirty-seven percent of comments in the focus group sessions (n = 277) addressed views of success either as a current medical student or in the future as a physician. Although professional/academic achievements (e.g., grades, subjective evaluations, exams, class rank, and competence in patient care) were important, participants said they also strove to maintain a sense of balance, happiness, and authenticity, and desired to positively affect their families and communities by serving as role models and providing needed medical care. Most participants placed a high value on receiving affirmation from patients, family members, and other community members. They also defined success in terms of financial wealth, but they clarified that they sought money to fulfill their need to survive and support their families, rather than to achieve individual wealth and status. Active participation in social and cultural activities was also important for minority medical students’ conceptions of success. They believed the priority they placed on giving back to their families and communities differentiated them from many of their white counterparts.
Facilitators of success
Twenty-two percent (n = 166) of comments were related to factors that the students believed promoted their achievements in medical school and helped to define their career choice in medicine. Facilitators of success are described below in the following four domains and their respective subdomains: scholarships, social support, professional exposure, and personal characteristics. Additionally, List 1 shows sample comments that study participants made regarding facilitators of success within these four domains.
Participants mentioned that scholarship opportunities available for minorities and for students in need were an important aid in attending school and promoting their academic achievements. Although students identified financial factors that facilitated their success, they also highlighted the fact that money alone did not enable them to be successful.
Most focus group participants stated that the most important factor that enabled their success was the social support that they received during undergraduate education and medical school. This category included support from family, friends and colleagues, religion, and school administration. Families were acknowledged for continual emotional support and encouragement; relatives’ excitement about academic pursuits often inspired participants and deepened their commitment to complete their medical training. Friends and colleagues were also considered essential to the support network. Colleagues in medicine provided mutual understanding of the hardships of medical education, but friends outside of medicine also provided an outlet from the academic world. Prayer, faith, and fellowship in church were also important sources of encouragement. Church was noted as an extension of family, a sense of belonging to the community, and a place for refocusing energy. It was also noted as a place where participants could escape racial issues, because they were not part of the racial minority among their church community. These family, friendship, and spiritual outlets were important for helping minority students to remain connected to their social and cultural lives, something they highlighted as an important criterion for measuring success in school and in their careers.
During medical school, minority students received support from advisors, mentors, and deans that helped them to discover opportunities for professional development, scholarships, and promoting diversity within their medical school. In particular, many students noted the assistance of their school’s office of minority affairs in providing emotional support, academic retention and recruitment efforts, and scholarship information.
Prior to entering medical school, several students participated in professional exposure programs (e.g., summer enrichment, preenrollment) that encouraged and prepared them to enter the field of medicine. Mentors also provided an invaluable opportunity for minority students to be encouraged to go to college and pursue medicine. Students noted that both physicians and nonphysicians had facilitated their pursuit of a career in medicine. Faculty, administrators, hospital staff, residents, and attending physicians promoted student achievement, learning, and professional development. In particular, students noted the importance of having supportive minority role models to take time to encourage their academic success.
Students also recognized personal attributes, such as race, language ability, and self-confidence, as facilitators. Race was noted as an important personal characteristic when interacting with patients, other physicians, and hospital staff. Participants spoke of their ability to comfort minority patients and their families in hospitals. Many students received compliments and affirmations from minority patients who appreciated having a minority “doctor,” often a rare occasion for minority patients. This affirmation provided an important boost of confidence for minority students and enhanced their perceptions of the impact they had on patients. Similarly, familiarity with colloquial language and being bilingual were skills participants identified as facilitators of success, especially with minority patients and those with limited English language skills. Latino medical students noted additional responsibility for providing cultural partnerships, through their language skills. Participants highlighted how their racial/ethnic backgrounds often created opportunities for them to effectively treat underserved patient populations.
Inhibitors to success
Forty-one percent of comments addressed inhibitors of minority medical students’ success. According to participants, while the presence of certain factors enabled success, the absence of these same factors inhibited success. Inhibitors of success are described below in the following six domains and their respective subdomains: lack of support, discrimination, cultural representation, testing, self-limitation, and financial factors; additionally, List 2 shows sample comments made by study participants regarding inhibitors of success within each of six domains.
Lack of support.
Participants described how their interactions with insensitive colleagues, educators, and even family members signified a lack of support for their medical career pursuits and inhibited their ability to achieve success and fulfillment; individuals who desired to support their efforts could in fact do the opposite. In some instances, participants said family members increased stress by their inability to understand the medical school experience or offer financial support. Ethnic majority colleagues and friends demonstrated ignorance and lack of appreciation for diversity experiences, which undermined URM students’ ability to form cross-racial study groups. Moreover, participants felt that their ethnic majority classmates and administrators paid undue attention to their minority-focused social gatherings and same-race friendships and led them to feel self-conscious about publicly holding these otherwise supportive gatherings. Participants also reported that administrators failed to adequately understand the need for diversity and to promote an atmosphere of acceptance. Several participants experienced situations in which faculty, attending physicians, and residents demonstrated a lack of support by ignoring certain students in the classroom or during clinical rounds.
Many participants implicitly attributed their lack of support from faculty and administrators to racism. Yet, students mentioned that the ambiguous nature of many of their experiences made it difficult for them to discern whether they were not receiving adequate support because of their low status as a medical student among physicians, or because of race. Some participants did describe direct experiences of discrimination based upon race and gender. Participants noted that their school climates did not always welcome diversity. Students who attended historically black colleges and universities (HBCU)s noted the difference in their experiences, but shared similarities in certain community settings.
Participants described discrimination based on race as being directed at them by classmates, attending physicians and residents, faculty, and patients. Gender was also noted as an important factor that influenced how faculty interact with students, increased feelings of isolation, and elicited a lack of respect from patients. Black male students particularly felt isolated because of the small numbers of black male colleagues in medical school and the lack of role models. On the other hand, black female students described challenges with being mistaken for a nurse because of their gender. School climate could also provide an atmosphere that did not promote diversity or allow students to report issues. Participants believed that their ethnic majority colleagues misunderstood affirmative action programs, scholarships, and admissions policies and demonstrated a lack of confidence in participants’ abilities. Personal experiences were recounted as documentation that discrimination still occurs and influences decisions on a daily basis. Such experiences often incorporated both racial and gender discrimination.
Minority students also felt an increased stress to represent their entire race, culture, or community in the classroom and on the wards. This often created substantial pressure to perform well and to offer insights and opinions they were not prepared to give.
In medical school, everyone encounters testing, but study participants noted difficulty with standardized exams as well as the other testing methods used to evaluate performance. These inhibited their academic and professional success. Other tests also proved challenging because of a lack of experience with the methodology of assessment in medical school.
Our study participants stated that some of their barriers were self-imposed or internally driven. They believed the self-doubt, lack of self-confidence, and depression that may often occur because of the academic rigors of the preclinical years and were associated with professional responsibilities during the clinical years could deter them from their goals. They said this self-doubt was often exacerbated by their “token” status; as one of the few members of their racial/ethnic group in their cohorts, they felt spotlighted and more self-conscious about their identity. They internalized the negative views held by others and began to question their legitimacy as physicians in training. They also felt this self-questioning could negatively affect their ability and desire to focus on medical coursework and service.
Participants mentioned that financial concerns posed additional challenges to their academic and professional pursuits. Many minority students felt the need to provide monetary support to their own families, even while they were still students. This pressure to financially support their families heightened awareness of personal sacrifice during medical training. Participants felt that the lack of financial support from family and reliance on student loans created more difficulty for them than it did for many of their majority student colleagues, who they felt received more financial support from their families. Such perceptions often undermined their satisfaction with academic and professional experiences.
To our knowledge, this is the first qualitative study to probe the perceptions of racial/ethnic minority medical students regarding facilitators of and barriers to their personal and professional success. In this exploratory study, medical students from underrepresented minority groups viewed professional and financial success in medicine as a pathway to achieving a quality of life that would preserve their personal and family values. They considered professional success a means to an end rather than an end unto itself, and they believed that they placed a greater emphasis on serving their communities than did many of their white counterparts.
Support from friends, family, and community were particularly important facilitators of minority medical students’ success; and many students expressed the need to remain connected to individuals and institutions that would support their academic and professional pursuits. Mentorship and financial support, when available from faculty and administrators, also facilitated minority students’ entry into and performance in medical school. Students shared personal experiences regarding important individuals who motivated, inspired, and guided them along the path to success.
Yet, most minority students felt that many inhibitors to their success were still present. They still identified their race as an obstacle to receiving the academic and social support they needed to succeed in medical school. Significant barriers to their success included personal experiences with discrimination, pressures to dispel negative stereotypes related to their cultural or racial backgrounds, and a lack of self-efficacy. Students believed this environment created heightened concerns with being negatively stereotyped because of one’s racial group membership and desires to dispel such stereotypes. This stereotype threat 20 often had a negative impact on their academic performance by creating cognitive distraction, self-doubt, and depression. Participants also expressed that unsupportive administrative practices, lack of financial support, and testing difficulty contributed to their discouragement and personal hardships.
Our findings are similar to those of previous quantitative studies that have elicited input from students in medicine and other disciplines.21–37 For example, previous studies have also noted stresses related to test scores, financial burdens, a lack of minority role models, problems with self-efficacy, and incompatibility of students’ cultural beliefs with the dominant culture of the institution to be barriers to minority students’ academic performance and success. Similarly, other studies have shown support programs, individual mentors, and support from family and friends who are also ethnic minorities to be facilitators of success.
The most valuable information this study may have uncovered is that minority medical students still experience barriers that have been a focus of attention in U.S. medical education for some time. Of particular concern is the finding that the minority medical students in this study continue to perceive bias and discrimination in their interactions with peers, administrators, and faculty at academic medical institutions. We believe that one of the strengths of this study is the use of qualitative methodology, which allowed us to identify a broader range of promoters of minority medical students’ progress through medical education and student-centered strategies to overcome existing barriers to their academic and personal success. Previous studies have used administrative or survey data, most often from academic administrators and educators who have important insights to offer, but whose responses may have been affected by their investment in the success of their support programs and whose perspectives may not reflect all of the experiences, concerns, and priorities of minority students.10–14,21–24
Although many important issues were identified, our study has limitations. First, focus groups are useful in identifying major themes but are particularly sensitive to interpretation by researchers given the qualitative nature of the data obtained. We attempted to overcome this potential bias by using independent reviewers with different areas of expertise and by requiring adjudication and consensus to develop primary domains. Second, focus groups were conducted with small, relatively homogenous groups of students, and selection bias may have occurred. Participants may have represented a limited range of perspectives. Although our participants were similar to the overall SNMA membership with regard to gender and racial/ethnic distribution, we had only a small number of first-year students, and the majority of our participants came from families with high levels of income and education; therefore, their experiences and opinions may not be representative of those minority students who were not recruited. Moreover, students who participate in minority-interest organizations may identify more strongly with their racial category than students who opt not to participate. Thus, active SNMA members and conference attendees may be more sensitive to issues of racial bias than minority medical students who do not belong to SNMA. Although our study was hypothesis generating, more work is needed to characterize the experiences, opportunities, and obstacles to increasing the number of URM medical students in U.S. medical schools and to quantify the impact of factors such as the ones identified in this study on personal and professional outcomes for URM medical students. Such studies might include a larger sample of students recruited in a systematic fashion from medical schools throughout the United States. Third, participants’ answers may have been affected by response bias or social desirability, given the sensitive nature of discussions about personal and family experiences, racial discrimination, and past injustices along their educational path. We attempted to overcome this bias by using an ethnic minority moderator, holding the groups in a neutral environment, and guaranteeing the students that their names and the names of their institutions would not be used in any presentations or publications.
Many barriers to academic success among minorities are present in the pipeline towards successful careers as physicians. Although this study did not comprehensively elucidate these barriers, comments from our focus group participants substantiate the need for a closer consideration of the role of professional exposure, standardized testing, and test preparation in recruiting and retaining minority students best suited for meaningful and productive careers. Examining these barriers may also increase the likelihood that URMs will experience success throughout their medical education and beyond. Because 50% of medical students may have decided to become a physician by the junior high level,37 it is important that future research assess the barriers to medical careers present in the education system for minorities beginning in primary and secondary school.
If future work confirms our findings, many of the factors identified in this study should be addressed by programs and policies that aim to increase racial and ethnic diversity in the medical profession. In particular, medical school faculty and administrators play a critical role in improving racial/ethnic diversity among medical students. They have the potential to provide invaluable mentorship, advocate for financial and academic support, address discriminatory practices in admissions and promotions processes, and promote the recruitment and professional development of minority faculty who serve as role models for URM students. Given the limited value of standardized test scores and grade point averages from college in predicting future academic performance of minority medical students, administrators and faculty should consider adjusting medical school admissions criteria to include other characteristics of applicants with better predictive validity for determining students’ future potential for success as physicians.38 Faculty and administrators might also encourage minority medical students to invest the time and effort required to cultivate and maintain authentic, supportive relationships outside of medicine, including family, friends, and community and church members, since these social support networks often enable minority medical students to maintain the sense of self-assurance and inspiration necessary to successfully complete medical school. Finally, because URM medical students believe their academic performance may be negatively affected by experiences with discrimination and stereotype threat, administrators and faculty should work to improve the institutional climate to promote true diversity through cultural awareness and education programs for all students, faculty, staff, and academic administrators. The evaluation of such programs should be broadened beyond measuring traditional quantitative indicators of success to including minority medical students’ perspectives regarding the organizational infrastructure and institutional climate for diversity.
The authors thank the Student National Medical Association for their support of this effort. Dr. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (K24HL083113).
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