Hung, Robert MD, MPH; McClendon, Jennifer MD; Henderson, Anita MD; Evans, Yolanda MD; Colquitt, Rosa PhD; Saha, Somnath MD, MPH
The medical student population of the 21st century is becoming more racially and ethnically diverse. Nevertheless, certain minority groups continue to be underrepresented in U.S. medical schools.1–2 The relative lack of racial and ethnic diversity at some medical schools may affect the educational and social experiences of both majority (Caucasian, or white) and minority (nonwhite) students in several ways. Minority students, and especially those from underrepresented minority (URM) groups, may feel isolated or experience the undue burden of serving as “representatives” of their racial or ethnic group within the student body.3 Such pressures may cause some students to isolate themselves within homogenous “in-groups” or to avoid medical schools with nondiverse student bodies altogether. Majority students may, in turn, emerge from medical school poorly equipped to work effectively in settings with diverse colleagues and patient populations (i.e., to be culturally competent) because of minimal exposure to classmates of diverse racial and ethnic backgrounds.4 Finally, with few minority students to acknowledge, medical school administrators may pay little attention to issues of racial and ethnic diversity even when they value student diversity and express support for it. The lack of cultural diversity within a medical school faculty and student body may send a message that the institution does not truly value issues relevant to minority populations. The presence or lack of ethnic diversity and real or perceived institutional support for diversity and cultural competence contribute to a medical school’s cultural climate, an intangible yet potentially important aspect of the hidden curriculum that shapes medical students’ attitudes and behaviors.5
Few published studies have examined students’ perspectives on diversity in medical schools.6–7 Those studies have focused primarily on students’ opinions about the influence of student body diversity and, to a lesser extent, on the influence of cultural competence training on the process and quality of medical education. We sought to expand this work by examining not only students’ own attitudes about diversity and cultural competence at their medical school, but also their perceptions of the attitudes of other students, faculty, administrators, and of the institution as a whole (i.e., their perceptions of the cultural climate around diversity) at their medical school. In addition, we sought to determine students’ perceptions of the reasons for racial/ethnic minority underrepresentation at their medical school and to determine how the attitudes and experiences of URM and other ethnic minority students differed from those of majority students. We also examined the differences in perception between students who declared themselves as part of the “majority” versus “minority” culture on campus, regardless of their race/ethnicity.
This study involved a survey instrument motivated, designed, and implemented by students at a medical school in the Pacific Northwest. The primary intent of the survey was to initiate efforts to improve the cultural climate around diversity at the medical school studied. In this report, we share our findings and, thereby, hope to stimulate further interest in the measurement and importance of the institutional climate around diversity in medical education, both in the school whose students we studied and in general.
We developed a novel survey instrument to assess students’ perceptions of the value of campus diversity and cultural competence and the cultural climate around diversity at their university. Four of us were medical students, and two of us were faculty members. We worked together to develop an outline of the topics to be addressed in the survey. We conducted a brief literature review and consulted with colleagues at other institutions for existing survey instruments used for similar purposes. Using these resources as a foundation, we developed an item list (i.e., a survey form) addressing the following topics: value of diversity, representation of racial/ethnic groups on campus, institutional commitment to diversity, cultural competence, inclusiveness, and racism.
We then conducted a series of four focus groups with an average of 10 medical students each, with representation from all racial and ethnic groups on campus. During the focus groups, students completed the survey form and provided feedback on face validity, clarity, and coverage of relevant topics. Based on student feedback and further discussion among study team members, we revised the form through consensus, to balance brevity, comprehensiveness, and clarity. The revised form and the study were approved by the medical school’s curriculum committee and institutional review board.
We invited all students enrolled in the medical school in the spring of 2003 (N = 398) to participate in the study. We administered the written survey forms to each class of students when they were gathered as a class for lectures. The school’s associate dean for medical education announced the study to each class and passed out the self-administered survey forms. Students completed the forms anonymously. As an incentive, students completing the forms were eligible to enter a lottery for bookstore and restaurant gift certificates. We compared survey responders and nonresponders on demographic characteristics using the medical school’s registration data.
We generated descriptive statistics for each item representing our primary topics of interest. Respondents rated the items concerning attitudes towards diversity and cultural competence on a five-point scale from “strongly disagree” to “strongly agree.” For these items, we report the percent of students who agreed (either strongly or somewhat) with each statement, except for reverse-directed statements, for which we report the percent who disagreed (strongly or somewhat). We dichotomized the responses in this way both for the sake of greater interpretability and because for many of the items, responses were skewed rather than normally distributed, making statistical comparison of mean scores between groups potentially problematic. The items concerning another topic, institutional climate around cultural diversity and race, were also rated on the same five-point scale. For these items, we report the percentage of students who agreed (either strongly or somewhat) with each statement, except for a single item on students’ perceptions of whether the university responds adequately to issues of perceived racism. For this item alone, the majority of students checked “neutral”, suggesting that they did not have experiences on which to base agreement or disagreement. For that item, we report the percent of students that either agreed or were neutral, to reflect the proportion of students who did not express a perceived problem with the university’s response to racism. Students were asked to respond “yes” or “no” to questions about personally experienced and observed instances of racial discrimination, and about perceived reasons for minority underrepresentation on campus.
We asked students to categorize their own race and ethnicity by checking “all that apply” from a comprehensive list or by entering a separate category not listed on the survey form. We also asked students whether they felt that they were a part of the “minority” or “majority” culture on the university campus.
We compared outcome variables among whites versus nonwhites, URM versus non-URM, and minority versus majority culture, using χ2 tests. To account for the potential loss of statistical power stemming from our dichotomization of scaled responses, we also analyzed the original scaled responses across comparison groups using the Kruskal-Wallis test. All comparison data were analyzed using Stata 6.0 (College Station, Tex).
Of a total of 398 students at the medical school at the time of our study, 216 (54%) completed the survey instrument. Survey responders were generally representative of the entire student body with respect to age, race/ethnicity, and gender (Table 1). Response rates varied among the classes, from 42 (40%) among second-year students to 68 (76%) among fourth-year students.
Students’ identification of their race and ethnicity
We categorized responses as follows: Asian (Chinese, Filipino, Indian, Japanese, Korean, Middle Eastern, Pakistani, Persian, South Asian, Southeast Asian), black (African American or African), Latino (Central American, Cuban, Mexican American, Puerto Rican, other Latin American, Hispanic), American Indian, white (white, Caucasian), or other. Students checking multiple boxes were considered nonwhite. We further categorized black, Latino, and American Indian students as URMs.
One hundred sixty-two students (75%) identified their race as white only. Among the 54 (25%) students identifying a race/ethnicity other than white, 17 (7.9%) checked more than one racial/ethnic category. Fifteen students (7%) were in one of the URM groups.
Students’ identification with the majority versus minority culture
Forty-five students (21%) identified themselves as not being part of the majority culture on campus. Of these, 41 (91%) were nonwhite students, and four (9%) identified as being white only. Fourteen (26%) of the 54 racial/ethnic minority students identified themselves as being part of the majority culture on campus. Of those 14, 6 (43%) were of mixed race/ethnicity (white plus another category) and six (43%) identified their race/ethnicity as “other.” Age, gender, and class year were similarly distributed among whites versus nonwhites, URM versus non-URM students, and students identifying as being part of the minority versus majority culture on campus (data not shown).
Attitudes toward diversity and cultural competence
As shown in Table 2, the majority of the responding students endorsed the value of student body diversity. Agreement varied across different statements about diversity, with the greatest number 181 (84%) agreeing that “having a diverse student body improves the medical school experience,” and the lowest number 121 (56%) agreeing that “being in a student body that is not ethnically diverse compromises the quality of my medical education.” Perceptions of the value of diversity did not vary significantly across our comparison groups, except for in one instance: when item scores on the five-point scales (rather than percent of students agreeing) were compared, students identifying as part of the minority culture were more likely than those in the majority culture to endorse the statement that “being in a student body that is not ethnically diverse compromises the quality of my medical education,” (mean score 3.84 versus 3.39, P = .03).
A majority of students also endorsed the importance of cultural competence (Table 2). More than three quarters of the students surveyed agreed that “information on working effectively with diverse patients and colleagues should be integrated into the curriculum.” Nearly all students 207 (96%) affirmed the value of knowing “the social and economic conditions and cultural beliefs and values” of patient populations, whereas slightly fewer 186 (86%) felt it was important to understand the history and cultures of different ethnic groups. Actual scores on this latter item suggested that more nonwhite than white students endorsed the importance of ethnicity-specific knowledge (3.47 versus 3.22, P = .05). Most students felt the medical school’s clinical faculty would benefit from cultural competence training; minority-culture students were significantly more likely than majority-culture students to hold this view.
Institutional climate around cultural diversity and race
Whereas a large majority of students endorsed the importance of diversity and of cultural competence, fewer felt those principles were adequately embodied in the institutional environment and values of their university. Roughly half of the surveyed students felt that the university had “created a safe and open forum for students, faculty and staff to discuss issues of cultural diversity, cultural competency, race, and perceived racism,” or that “issues of cultural diversity are usually discussed openly and freely” (Table 3). However, white students as a group recorded lower scores than nonwhites in terms of feeling comfortable offering their perceptions on cultural issues (4.08 versus 4.44, P = .03). About three quarters of surveyed students felt that the university had achieved a climate of acceptance and equity. However, over 20% of all students, and nearly half of URM students, agreed that racism still exists at the university.
Students were mixed in their opinions about the institutional values at their university. Two thirds agreed that the university paid adequate attention to diversity in their mission statement, programs, and offices (Table 3). However, fewer students overall—and many fewer nonwhite, URM, and minority-culture students—felt that the university truly valued having a diverse student body, faculty, and administration. Nonwhite and minority-culture students were also less likely than white and majority-culture students to feel that the university was paying adequate attention to cultural diversity in terms of sponsoring “systematically coordinated activities…designed to build a family of diversity at the university.” As stated earlier, most students were neutral on the issue of how the university responds to racism, but notably, minority-culture students were more likely than majority-culture students to feel that university did not respond adequately.
As shown in Table 4, among all students, 21 (approximately 10%) had personally experienced and 44 (20%) had observed instances of racial discrimination on campus. These experiences occurred more in clinical settings (e.g., ward rotations) than in classroom or social situations. As expected, nonwhite and URM students were far more likely than others to experience discrimination. URM students were significantly more likely than non-URM students to report having observed racial discrimination as well.
Perceived reasons for minority underrepresentation
As shown in Table 1, 315 (79%) of students at the medical school at the time of this survey were white. This is a higher proportion of whites than in the general U.S. population,8 though slightly less than the proportion in the population of the state from which the medical school draws many of its students (75% United States, 86% state).9 Nevertheless, black and Latino students were underrepresented in comparison to their representation on the national, state, and local population levels.10 We asked students to speculate as to the reasons for this underrepresentation.
Relevant to the impact of cultural climate, nearly two thirds of students felt that the relative lack of diversity at their medical school hindered the recruitment of minority students (Table 5). Nonwhite, URM, and minority-culture students were more likely than others to cite lack of social, academic, and financial support, and inadequate recruitment efforts, as reasons for low minority representation. About a quarter of students did not believe minorities were inadequately represented, and interestingly, this perception was more common among nonwhite, URM, and minority-culture students, though differences were not statistically significant.
In this student-driven study, we sought to gauge the cultural climate around diversity at one U.S. medical school with relatively few URM students. We found that, overall, students endorsed the value of diversity to the medical school experience and the importance of cultural competence to the process of becoming a clinician. Fewer students (though still a majority), and fewer nonwhite and minority-culture students in particular, felt that the university also valued diversity and had achieved a positive cultural climate, characterized by openness to diverse perspectives, acceptance, and attention to equity. A total of 44 students (20%), including 7 URM students (47%), perceived racism to exist at the university and in fact reported having observed instances of racial discrimination on campus, mainly in clinical settings. Most students felt that the lack of diversity on campus was a barrier to recruiting and retaining minority candidates. A third to a half of minority students also blamed limited social, academic, and financial support at the university, as well as inadequate efforts to recruit minority students.
In addition to these global findings, several more specific issues warrant mention. Most students felt that their university’s policies and programs reflected an interest in diversity. This may have reflected recognition of several recent changes at the medical school, including appointing an assistant dean for minority affairs; appointing a student and faculty taskforce that produced a statement of commitment to improve the cultural climate through enhanced student education and recruitment and retention of minority students and faculty11; and solidified funding for the university’s office of diversity and multicultural affairs. But fewer students, minority students in particular, agreed that the university valued having a diverse student body. Minority students were also more likely to perceive that the university could do more in the way of recruitment efforts and provide more social and financial support to enhance campus diversity. This suggests that students gauge cultural climate not only by the “structural” elements (e.g., programs and policies) of the university’s commitment to diversity, but also by the “processes” (e.g., recruitment efforts, social support) and “outcomes” of that commitment (e.g., actual campus diversity).
We were able to analyze our data across groups defined by both race and ethnicity (nonwhite versus white) and by perceived relation to the dominant culture on campus (minority versus majority). Although there was substantial overlap between nonwhite students and minority-culture students, the groups were not identical. In most cases, we found that minority-culture students differed from majority students more often than nonwhites did from whites. This highlights the important point that race and ethnicity are different from culture, and that when assessing institutional climate around diversity or other issues, it is possible and important to evaluate perspectives across racial and ethnic as well as cultural groupings.
Although a majority of students endorsed the importance of diversity and cultural competence, the majority was relatively narrow for two statements that posited that (1) lack of diversity compromises the quality of medical education (121, or 56%, of students agreed), and (2) the clinical faculty would greatly benefit from cultural competence training (143, or 66%, agreed). There are several possible explanations for this finding. Students may believe that diversity and cultural competence are beneficial to medical education but that their lack is not particularly detrimental. They may also consider diversity and “cultural” competence to be peripheral to “medical” education and, in turn, to the effectiveness of “clinical” faculty. In other words, our findings may simply reflect the fact that in this medical school, as in most, the biomedical model still dominates the bio-psychosocial model as the basis for medical education.12 Notably, minority students were more likely to endorse the need for cultural competence training for faculty, suggesting that, as persons from minority social and cultural groups, they may be more attuned to the inattention of medical educators to the social and cultural aspects of medical care.
Most students reported feeling comfortable talking about diversity, racism, and culture. However, white students were significantly less likely to say that they felt comfortable expressing their perceptions on “cultural issues.” Although we can only speculate about the underlying meaning of this finding, we suspect that some white students may feel that, as members of the ethnic majority population in the medical school, their perspectives on issues more closely identified with minority groups are undervalued. Alternatively, they may feel uncomfortable expressing views they fear may not be “politically correct.” Whatever the underlying reason, the finding suggests a need to ensure that all students feel comfortable expressing their views, since open dialogue about cultural issues will in most cases be preferable to repressed opinions.
Not surprisingly, URM students in our survey were more likely than others to report having experienced racism on campus. Interestingly, they were also more likely to report having observed racist incidents perpetrated against others. This may reflect a heightened vigilance or simply greater experience and familiarity with racist behavior. Alternatively, it may reflect that URM students often tend to cluster together socially and may therefore be more likely to observe racist behavior directed at other minority students. In either case, the finding highlights that URM students have unique perspectives that should be considered in assessments of institutional climate.
The most frequently cited reason for underrepresentation of minority students on campus was a lack of cultural diversity at the medical school. Though we did not ask directly, we suspect that in responding affirmatively to this potential reason for minority underrepresentation, most students were referring specifically to the relative lack of racial and ethnic diversity on campus, both among students and faculty. This highlights the catch-22 faced by many medical schools with low minority representation: it is difficult for schools to attract URM students until they have reached a critical mass of URM students. However, if the views of many of the minority students in our survey are correct, schools without a critical mass of minority students may be able to reach that critical mass through greater financial support and aggressive recruitment efforts.
Few studies have investigated medical students’ attitudes or perceptions about diversity.6,7,13 In one study at a Chicago medical school, over 90% of respondents agreed that “all doctors need to be aware of the different cultures within their practice.”13 In a telephone survey, Whitla et al6 found that the majority of medical students at Harvard Medical School (HMS) and the University of California, San Francisco, School of Medicine deemed a diverse student body and clinical faculty “very important” in improving medical education. Discussions with peers from other ethnic backgrounds influenced the way nearly half the students thought about equity of the health care delivery system, access to medical care for the underserved, and cultural competence when treating a diverse population. Minority and nonminority students valued diversity equally. In contrast, a survey by Elam et al7 revealed that minority and majority students at four southeastern U.S. medical schools perceived things differently. African Americans were less likely than other students to think that the curriculum contained adequate information about diversity or that the faculty was knowledgeable about issues of diversity. One of the more racially and ethnically homogenous schools had more respondents who agreed that “discussions about diversity shifted attention away from more important course content.” Our findings were consistent with most of these studies, showing that most students valued diversity and cultural competence, but that minority and majority students often had differing perspectives.
Our study had important limitations. We surveyed students at a single medical school, which may limit the generalizability of our findings. The small URM population at this medical school may have limited our ability to detect significant findings among URM groups. We believe, however, that it is important to highlight the potentially unique experiences of URM students in settings where they represent an “extreme minority.” Although we made the survey anonymous so as to solicit honest opinions, students’ views may still have been affected by “social desirability” bias, the tendency to provide responses perceived to be “correct” rather than those that reflect one’s true feelings.
Finally, just over half of the students enrolled at the medical school completed the survey form. This response rate is similar to that in previously published reports of student surveys on similar topics.3 However, it is possible that students who did not participate hold systematically different views from those who did. For instance, some students may have chosen not to participate because they did not consider diversity an important topic. Alternatively, students may have opted out because they did not have grievances to air about the university’s cultural climate. In either case, incomplete response rates illustrate an inherent difficulty in using voluntary surveys to gauge any organization’s cultural climate.
One way of compensating for lack of complete coverage across the student body may be to add depth to the assessment by supplementing surveys with qualitative methods. Although we did not systematically collect qualitative data, some students added comments to their surveys that highlight the potential for qualitative interviewing to enrich cultural climate assessment. One American Indian student wrote, “The ‘discrimination’ I have experienced came as a result of holding ideas about medicine and society that are more typical of people of color. If I’d kept quiet about my opinions on how race/ethnicity and medicine intersect, I’d have much fewer problems.” A white student wrote, “I can’t believe there’s an Office of Diversity and Multicultural Affairs. The resources should be devoted to something more useful to the entire student population rather than only underrepresented minorities…it exists to make people feel good about themselves, nothing more.” These widely varying and passionate views about cultural and racial/ethnic diversity provide depth and meaning to the numbers generated in a survey. Collecting this type of information may prove difficult, because standard qualitative data collection methods such as focus groups and interviewing would not provide the anonymity that is probably necessary to elicit strong views on this topic. Anonymous essays, such as those used in forums about commissions of medical error, may be one avenue to these perspectives.
In conclusion, we found that students responding to our survey generally placed a high value on campus diversity and cultural competence as factors contributing to their education and development as clinicians. Students felt that the university’s commitment to diversity was adequately reflected in their programs and policies, but minority students in particular felt that the university could do more to operationalize that commitment, including making greater efforts to recruit and retain URM students. Views such as these constitute an important barometer that medical schools can use to gauge and track their efforts to enhance campus diversity, incorporate cultural competence education, and create an inclusive and welcoming climate for students of all backgrounds.
The authors would like to thank Drs. Edward Keenan and Molly Osborne for their support of this project, and all the students and faculty members who contributed to the development and completion of this study.
Dr. Saha is supported by awards from the Advanced Research Career Development program of the Health Services Research and Development Service of the Department of Veterans Affairs, and from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program.
The views expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs or the Robert Wood Johnson Foundation.