Thomas, Brett MS; Manusov, Eron G. MD; Wang, Aihua MA; Livingston, Helen EdD
Increasing the number of black physicians in medicine is a goal that continues to receive attention from researchers and medical schools.1–3 Medical schools have focused on increasing the diversity of medical students as a means of increasing the diversity of the physician workforce. A diverse physician workforce is needed to ensure that the number of physicians that care for underserved communities and populations is adequate, to increase the level of research targeted to diseases that have a disproportionate impact on minority racial/ethnic populations, and to increase the participation of members of minority racial/ethnic groups in clinical trials designed to alleviate health disparities.1 Patients are also more likely to feel comfortable in all aspects of a relationship with a physician of the same race or ethnicity, increasing patients' compliance with medical interventions for chronic and urgent disease.4 Currently, black Americans constitute approximately 13% of the U.S. population. They account, however, for only 4% of the U.S. physician workforce.3
Although medical school applications from black students have increased, the increase has been noted primarily among black women.1 During three consecutive years (2005–2007), nearly two-thirds of black medical school applicants were women.1 In 2010, black men accounted for the lowest percentage of medical school matriculants from all major racial/ethnic groups.1 Medical educators and researchers do not completely understand the reasons for the disparate application and matriculant rates for black men and describe obstacles, such as limited exposure to medicine (e.g., lack of black mentors), lack of family and peer support, and financial challenges.3 A study by Thurmond and Cregler2 indicates that lack of early involvement of minority mentors and challenging science courses, such as chemistry, may lead to the early dropout of students from underrepresented minorities from pipeline programs that target students from rural and disadvantaged backgrounds. Researchers have focused in the past on barriers to black men in health care careers but have seldom tried to identify contributors of success in medicine for black men. We carried out the present study to determine characteristics and individual experiences that contribute to the success of black male students in being admitted to and graduating from Florida State University (FSU) College of Medicine.
Participants and recruitment
Following approval of the study protocol by the FSU human subjects committee, we recruited a cohort of 10 black male medical students enrolled at FSU College of Medicine and 3 black male physicians associated with that school. To reduce selection bias, the 3 physicians were chosen randomly from among the practicing physicians in Leon County, Florida, who also serve as clinical faculty at the medical school. Because there were only 12 black male students enrolled at the college of medicine, we asked all of them to participate in the study. (One of the 12 did not respond to our offer, and another was unavailable for interview because of scheduling difficulties.) The physicians and medical students were contacted via e-mail with the request for participation. The informed consent form, self-administered questionnaire, and project scope were included in the e-mail to provide prospective participants insight into the study. The principal investigator (PI; B.T.) provided a small meal but did not offer any other incentive. He told the participants that the purpose of the investigation was to determine contributors and obstacles to success in medicine of black medical students and physicians and that the study fulfilled the interviewer's requirement for a master of science degree program. The interviewer guaranteed the participants' anonymity.
We conducted a review of the literature on black male and minority experiences and perspectives on careers in medicine, racial identity, academic success and barriers for minorities, minority outreach and pipeline programs, resilience among black youth, predictors of success in medicine, the effects of black culture, self-esteem and cultural coping styles, achievement patterns, needs that are identified as a norm (normative needs), and opportunities for success for black men in medicine.4–10 We used open-ended questions and information gained from the literature review (see List 1). The PI, an African American man enrolled in the masters degree in biomedical sciences Bridge to Clinical Medicine program at FSU College of Medicine, contacted each eligible participant (both students and physicians), arranged for the meeting at a convenient time and place, and interviewed each one. Before the interview, each participant signed an informed consent form. The PI collected demographic information on age, cultural background, religious and spiritual constructs, and economic background. The interviewer scheduled 60- to 90-minute face-to-face interviews at each participant's place of work or at FSU College of Medicine during the workday, at a time that was convenient for the participant.
The interviewer asked a predefined list of open-ended questions (shown in List 1) and, as protocol allowed, asked questions for clarification or to further investigate answers. The semistructured interview format allowed for in-depth and detailed discussion while minimizing bias introduced by the investigator's questions. The interviewer continued until saturation was reached and no new information was forthcoming as per qualitative research methodology. The interviewer audio-recorded each session, and graduate students transcribed those recordings.
The investigators used consensual qualitative research (CQR), a qualitative approach that incorporates elements from phenomenological, grounded theory, and comprehensive process to analyze the data.11 Phenomenology is the systematic reflection on and analysis of phenomena. Grounded theory is a systematic research methodology emphasizing the generation of theory from data during the process of conducting research. Two of us (B.T., E.G.M.) independently listened to all interviews, read all transcriptions, and coded for themes (domains) and core ideas. We listened to the digital recordings in order to consider variations in tone, meaning, hesitancy, and alluding remarks for appropriate assessment. After coding each interview separately, the two of us completed the process of initial review of comments and themes. To reduce group decision-making bias and to strengthen interpretation, a third member of our investigative team (A.W.) served as judge, reading half of the interviews and then joining the analysis after the first two investigators completed the initial analysis. The final investigator (H.L.) served as an auditor, reading and listening to a random sample and joining the group to further ensure the validity of data interpretation.
As stated earlier, there were 12 black male medical students enrolled at FSU College of Medicine in 2009–2010. One student declined to participate, and one student was unavailable for interview because of scheduling difficulties. There were 13 black male physicians in the Tallahassee area. The first 3 physicians contacted agreed to participate. The demographics of the sample are shown in Table 1.
The contributors to success
Content analysis of all 13 interviews yielded 135 comments, which we separated into two broad categories of contributors to and obstacles to success. We divided the contributors to successful admission and completion of medical school into six broad domains: social support, education, exposure to the field of medicine, group identity, faith, and social responsibility. The interviewers then identified core ideas or connections (axial codes) and grouped them within the domains. We kept the core ideas as close to the participants' perspectives and explicit meanings as possible, free of assumptions or interpretations of the exact wording participants used. Examples of typical comments from each domain are included below. We have not altered the quotes or revised occasional colloquial usage, but we did streamline them occasionally and inserted explanatory words here and there to make certain passages understandable and to show how we interpreted the quotes.
All the participants considered social support important to the pursuit of success, and categorized support into two domains: family support and other social support. We made the distinction between family support and other social support because although social support was mentioned by most participants, all participants specifically emphasized the importance of their family support. Other social support is defined as support from an advisor, mentor, role model, and peers.
Family support. All of the participants identified family support as a significant contributor to success. Parents, guardians, and siblings provided positive encouragement and support for the participants, instilled value in education, and emphasized educational endeavors even though they used multifaceted values and methods.
They [parents] knew what a lack of an education, especially for a black man ... means ... it's not a good picture, so you don't want to go down that path, you know, I actually remember my dad did something with me that he said his dad did. He took me around [city redacted] and ... it's still somewhat segregated, you know, there's the north side, and that's pretty much where a lot of blacks stayed and ... the beach side, where a lot of whites stayed ... but we lived in a pretty mixed community. But he took me on the black side of town, and showed me some people, you know, [other] people just would see them and think, “They are probably just a crack-head or something,” and he's, like, “I went to school with him,” and ... when my dad did this, he had to be in his 40s, and this person looked like they had to be at that time 50 or 60.... He was doing with me what his dad did, and he said the point of this is to say, “You have a choice. Now, the choice that we are trying to instill on you to do is to go to college and be a productive citizen in society, and you can be like us,” and pretty much they wanted me to be better than them, they always say that.... “Or you can be like this.”
The participants' families enrolled their children (who became the participants in our study) in magnet programs and required their best effort in their classwork. In many cases, parents would sacrifice or forfeit their own aspirations to ensure educational exposure for their children. Parents often moved from a county, state, and even country so that the participants could receive better educational experiences.
My mom didn't want me getting bused down there. So, she actually moved to the school so we could be near the school, and my brother actually went to the middle school that I went to.
Families instilled other values, such as a strong work ethic and racial/cultural/religious pride. For those interviewees coming from families of low socioeconomic status, watching their families work hard and working hard themselves contributed to the development of a strong work ethic. Values pertaining to religious beliefs and cultural background strengthened their support net, improved social capital through church and racial/cultural ties, and, they believed, contributed to their success.
It would probably be work ethic. I think that the stereotypical Jamaican mindset is to have as many jobs as possible.... So, the work ethic, always doing something even if you didn't have the education or weren't in school, but working, trying to better yourself, I think that's the kind of cultural background that I come from.
Social support: advisor. Many of the participants reported interactions with a premedical advisor during their undergraduate education. This relationship yielded guidance on the necessary steps to ensure competitiveness in the medical school application pool. It was particularly crucial for the interviewees, who lacked other means of social support and/or knowledge about the process of applying to medical school. One participant stated:
He [premed advisor] helped me a lot; he helped me get on the right path. I remember the first time going into his office and he said, “What are you doing with your life? You have been here how long and I haven't met you and you are premed?” He got me on the right path and got me on the right thinking and helped prepare me.
As the above quote shows, advisors also served as a source of encouragement. In addition to providing individual encouragement and information, advisors shared inspirational stories about students from similar backgrounds who had succeeded, providing insight, inspiration, and motivation to the participants.
Social support: mentor. The majority of the interviewees described receiving support from a mentor. The mentor served a multifaceted role, from being the source for values and advice to conveying guidance on pursuing higher education. For some participants, who were not confident enough in their ability to succeed in medicine and who began to consider other professions, mentors helped the participants believe they had the ability to reach their goal of becoming a doctor.
Some participants also described a mentor as serving as a parent figure for those who had no significant family support:
I don't know if he [the mentor] knew that I didn't have a father or my father wasn't in the home. I don't know what but he took care of me, really. When I got the trophy for having the second-highest GPA, the guy that had the first-highest GPA sat across from me in ... class, and when my name was called for the second-highest GPA, he [the mentor] stood up and started clapping.
The interviewer explored the significance of the race of the mentor with the participants. The common sentiment was that the character of the mentor was much more significant than the mentor's race; however, if race and/or culture are shared, it was “like icing on the cake.”
Having a mentor is really important ... having anyone there is important, period. Having someone who looks like you, that's bonus, that's even additional motivation.... You can have the same quality, level of mentorship from someone who looks like you and someone who doesn't, and I think that [the] mentee would respond more to the person that looks like them ... even subconsciously.
Social support: role model. Half of the interviewees expressed that a role model was influential in their pursuit of medicine. The majority identified their role models as being black or African American men; however, other ethnicities were also identified:
The role model for the pharmacy was very nice, he was a Jewish man who helped us ... gave my brother and I jobs.... I think that the combination of working in the pharmacy, dispensing meds, working the cash register ... delivering meds ... tearing up some trucks ... doing the orderly thing ... is what kind of ... finalized it for me [to pursue medicine].
With regard to the importance of race and culture, one interviewee described his role model:
My ophthalmologist is, like, the greatest doctor I have ever went to, he's an African American as well, and kinda feels like he sees himself in me ... cultural aspects are similar, the strong Christian faith, the big family ... he's very charismatic, very funny.
Some participants explicitly reported that black men must act as role models:
I know that when I walk into a room, I'm representing you [a name of a black male medical student]. When I walk into the room I know that [a name of a black male medical student] has to come, I have to make it happen. I know that me getting AOA, me getting Gold Humanism, has nothing to do with [me].... Because if you see me get it ... so, dang, you say, I can do it now.
One participant also charged one of us (B.T.) with this same type of role modeling:
But the thing is, role models [are key to black men's success]. It's you guys who are coming along to be the role models. So the weight of the world, sir, is in your lifestyle.... I'm just glad you are doing this [study].
Peer support. For half of the participants, peer support proved significant. Those peers who were pursuing the field of medicine or other fields that required postundergraduate training and education often supplied the needed support. The interviewees received a “pseudofamily” support from their peers who could relate with and assist them in their endeavors. One participant illustrated the dynamics of the relationship with a peer as follows:
[He] is actually at ... the Medical College of South Carolina, and he was one of the people who we talked about everything, did everything together, we studied together, and we had some of the same crises ... we took practice quizzes together, and we pulled all-nighters together, we did everything together, and that kept us both along the same path. Mission-wise, we did the same thing: We critiqued each other's personal statements, we both went to see [the advisor] mostly at the same time and talked about different things that were going on and sought his advice.
Responses relating to gender, race, or culture, and other similarities significant in the relationship, varied and produced no conclusive data. However, the interviewees identified peers moving in the same direction (e.g., field of medicine, college education, and positive outlook) as support and as contributors to their success.
All the participants had engaged in honors course work in secondary school whether the institution was private or public. In addition, 11 of the 13 interviewees had participated in a gifted or magnet program. The curricula of the programs consisted of advanced placement (AP) and/or international baccalaureate (IB) courses. Several of the magnet programs specifically targeted the field of medicine. The simulated medical school environments provided enrichment opportunities to enhance knowledge in the sciences, and a solid preparation for future medical education.
Curriculum implementation and positive encouragement provided by teachers proved instrumental. Many interviewees attended school in an urban area, and even though they were involved in AP and IB classes, their schools lacked resources such as up-to-date textbooks and computers. The role of the teacher was integral to their success. Teachers fostered the participants' personal motivation, competence, and goals:
... and her expectations were top of the ranking. She would give you a paper back and you will feel like you did your best job on it, and it would come back looking like it was murdered because there was so much red on the paper ... she use to do interviews with us to try to get us ready for jobs. That wasn't in the curriculum.... But she taught me how to write. She taught me how to express myself. I write poetry now, and I'm not sure if I would be writing if it wasn't for her. I wrote essays in order to get scholarships and I got a lot of scholarships coming out of high school, and that was because I learned how to write because of her.
Interestingly, both of the participants who were first-generation immigrants from Jamaica emphasized the accelerated and advanced educational system in Jamaica compared with the one in the United States. They reported being ahead of the U.S. curricula in their course work when they first moved to the United States.
Exposure to the field of medicine.
All the participants had exposure to the field of medicine from various venues. The exposure allowed the participants to gain insight into the lifestyle, responsibilities, and knowledge associated with a medical career, sometimes solidifying the decision to pursue the study of medicine:
I took a class where I did rotations. I got to see, I don't know, somewhere around 30 different types of physicians. I got to see surgeries, and I was, like, this is for me. I want to do this.
Four of the 13 interviewees reported learning about the field of medicine from immediate family. Other avenues included summer programs, elective courses, and organizations developed to provide premedical enrichment in college. One common program to the participants was the Minority Association of Pre-Medical Students (MAPS) through the Student National Medical Association. MAPS and other similar outreach programs with a premedical focus provided the participants with opportunities for networking with other premedical students, medical students, and physicians through conferences, speakers, and, most important, shadowing experiences.
Fifty percent of those interviewed spoke of group identity as a contributor to success, beyond the support and cultural/racial pride that they gained from their families. The participants described characteristics and values introduced during their childhood and adolescence as a member of a cultural/ethnic/racial group that motivated them to succeed. For example, those men from Haitian or Jamaican backgrounds spoke of the strength of ethnic and cultural bonds and a philosophy of life that was assimilated through all of their social relationships. There was a pride in the Haitian or Jamaican emphasis on education.
There's two things that the Haitian culture views as, you are successful, you have made it. And that's to become a doctor or a lawyer. So ... that was with me from when I was a little kid ... and it's kinda like if you don't do those two things, you haven't really made it in the Haitian culture ... it's like God, Jesus, and doctors in Haiti ... you're like up there because you can fix people.
Those participants who identified themselves as African American described similar themes that we grouped into the domain of group identification, such as work ethic, religious/spiritual values, educational attainment, and family emphasis on career decisions. But the African American participants were more likely to describe those men who did not share the same drive to succeed. Group identification motivated individuals to succeed, provided social support as mentioned earlier, and brought them closer to like-minded people. At the same time, group identification provided plenty of lessons learned from others who failed. One interviewee highlighted these as follows:
The environment that the majority of African Americans were raised in, it [made it] so much easier to go to jail than go to school.
Six interviewees stated that faith was significant to the pursuit of their success. Five of the six interviewees explicitly identified with the Christian faith. One participant did not state that the Christian faith was important but indicated that his own faith was pivotal to his own success. In addition to the particular doctrine influencing personal attributes, such as attitude and perception of outcomes, faith also provided the participants the revelation of predestination (i.e., a plan is set for their life). Their faith allowed them to hope and provided them with motivation. For some, their faith explained why obstacles existed in life and provided the motivation to overcome these obstacles. For the interviewees growing up in inner-city areas where the danger of crime, drugs, and violence were prevalent, they described God as their protector.
We lived in a part of Miami called Over Town.... A lot of crime. A lot of drugs. We were exposed to a lot of things growing up. It's kind of strange because I tell people that I felt like God has us in a bubble because even though there was so much going on in the area—I mean, [I] saw a guy killed when I was eight or nine years old, I saw robberies and all kinds of stuff—but nothing happened to us. We use to just walk around drug addicts and things like that but nothing ... really happened to me.
Others described their faith as the fuel for their desire to succeed. For some, it was the social capital/support/group identification, for others the theology, and for others the motivation to become congruent with the faith that contributed to their success.
Participants described how their sense of social responsibility not only influenced their desire to be a physician but also motivated them to succeed. Every participant stated that the ability to help those in need significantly motivated him to pursue the field of medicine, and that motivation fueled a personal drive or goal, fulfilled a need, or defined a personal characteristic. Social responsibility was not only a motivation to pursue medicine; the participants also spoke of how their experiences of altruism and service to others opened doors and influenced other contributors to success such as finding mentors, educational experiences, exposure to the field of medicine, and support. Their emphasis on social responsibility was in addition to healing patients and making an impact on a community's health outcomes. The interviewees also described the community services that the profession of medicine can provide—such as mission trips, community outreach programs, family support, and mentorship—as providing drives to succeed. In the quote below, one participant revealed his plan to provide such service in the community in the future, a plan that framed his personal success:
My organization that I alluded to, I was going to call it [redacted to conceal identity].... I was just going to use the connections that I've made as far as the NFL and things like that, with some of these college players and things like that, and use my professional connections to really set up connections with African American youth and getting with these different people. Whether it be a summer opportunity or whatever it might be, but have them have the opportunity to get out of wherever they are, get out of the environment and follow this person around. See what his life is really like so you can have a better idea of what you need to do to get there or just broaden your horizons so you don't have to keep seeing the same thing day in and day out.
The obstacles to success
The participants identified the second broad category, the obstacles to success, from the 135 comments. We coded them as challenges. The most common obstacles to success were community challenges, educational challenges, lack of social support, financial challenges, societal views, and poor performance on standardized testing.
Eleven of the 13 interviewees described challenges experienced in their surrounding environments during childhood and adolescence. For the individuals growing up in urban and urban-like environments, crime, drugs, and violence were prevalent. One interviewee described his community as follows:
You had a bunch of drug dealers ... it was destitute, it wasn't too much positive around you, and the positive things around were on the other side of town, to the extent where the white people stayed.
Participants recalled peers and family members succumbing to the obstacles in the surrounding environment. When comparing the inner-city environments with the environments of those raised in affluent families and communities, one interviewee illustrated the differences:
You have to be a screw-up to not succeed if you grew up in an affluent family. If you grow up, for instance, where I grew up, in the inner city you have to push yourself to succeed. You have to create it on your own. That's the difference.
A majority of the interviewees raised in the urban and urban-like environments also described the disparities in the quality of education between their neighborhoods and more affluent districts. All the participants were involved in magnet or AP programs, but when they started in college, that experience was not always comparable to the same programs located in high-income areas. Having the proper resources was a big challenge, as one participant described:
We didn't have the resources; we barely had books that were up-to-date. I remember I took two AP classes, U.S. Government and Bio class, and we did not do any of the labs for AP Bio because we did not have any of the material.
Teacher quality and stimulation were also important to success. Participants reported low expectations and lack of encouragement from teachers as well as teachers' lack of enthusiasm for their profession. It led to negative educational outcomes for the students in the classes taught by those particular teachers. One interviewee explained:
And for U.S. Government [class], my teacher did not care to teach us anything. When we got to the test for AP U.S. Government, we all sat down and looked at each other and then the proctor that was walking around said, “Why isn't everybody completing the exams?” We told her that our teacher didn't teach us anything and she asked who our teacher was and we told her and she said “Oh, okay!” She was already accustomed to that happening because it happened the prior year.
Lack of social support.
A paucity of social support in one form or another (e.g., family, mentors, role models, peers) was also expressed by half of the interviewees. One participant described his experience when he first immigrated to the United States facing a new culture:
When I got to Howard University ... I knew nobody ... when I got there, the culture was not mine. They were dancing to all this American music, and I was use to reggae and soul ... a lot of beer and liquor.... I'm a 18-year-old kid, away from home.... I had no friends, no family, nothing close by. Totally different scene, so I went home [dorm].... Because I didn't fit in into the Howard University lifestyle.... I never got use to it, actually.
A lack of a mentor and/or role model was also reported by many participants as an obstacle. Not having a mentor/role model available in their community was described by two participants:
I had no idea of said timeline, I knew the courses I needed but had no idea of anything else. I had no idea of when the application process was supposed to be started, I had no idea when the MCAT was supposed to be taken, and I knew nothing in regards to actual admissions.
I was thinking about pharmacy, because I really liked it from an intellectual aspect and I figured I could help people. I didn't think about becoming a physician early on because I didn't see any African American physicians, so I didn't really think it was something you just could go do. I thought you had to know somebody and know somebody that knows somebody.
For many, athletics and sports were important, and their coach acted as a role model or mentor. However, for many black men, one participant described how sports and, in particular, the coach, can be an obstacle:
One day I skipped practice to go to an AP study session and then the same coach put me in a penalty period for skipping practice. There was a complex there where he wanted me to do good in school but he didn't want me to miss practice, so it really wasn't books before football, it was just for show, written on the shirt.
Eight of the 13 participants reported financial obstacles in the pursuit of medicine. Financial challenges were related to socioeconomic and family dynamics (e.g., single-parent home), education, and educational resources. For example, one participant recalled obstacles in preparing for the MCAT examination due to financial constraints:
Because I couldn't afford to go to [name of college institution] on my dime, let alone pay for a $3,000 class supplement to what I already had to pay plus living expenses. For me, I had to study out of some MCAT books my sister sent me from 2003.... I didn't score as well as my counterparts but I didn't have the resources and the monetary means to obtain those resources.
All the participants acknowledged the existence of stereotypes against black men (both African American and others) in U.S. society. The participants also recognized the scarcity of black or African American men in their medical school class and in the profession. The impact of the perceived stereotypes on the three black physician interviewees was explored in the interview with questions about how the participant felt being one of the only black medical students or whether he believed that other members of the class treated him differently because of his race. Although the responses varied (e.g., “I felt lonely in my classes,” “I had to work harder to prove something”), perceived society bias was not considered an obstacle. However, the majority of the participants did confirm that the lack of black men in medicine does affect networking capabilities in the profession.
Some of the interviewees also experienced societal stereotypes directly in their pursuit of medicine:
A lot of classes are curved. They figured that I was helping the curve [because I am black] and then proceeded to have a discussion with me.... I just set them straight. I was like, “I have an A− right now and I'm trying to get an A. You're kind of getting in the way of me studying.” And they realized that I wasn't helping the curve.
Six participants discussed the hurdles of difficulty with standardized testing in the pursuit of medical school. Some had difficulties with the MCAT, and two had to retake the United States Medical Licensing Examination Step 1. However, the reasons for standardized testing performance as an obstacle were not explicitly elaborated on. Three of the six interviewees attributed poor performance to test-taking shortcomings. For example, one participant said:
I am not a good standardized test [taker] ... in [a] standardized test, I freeze. Especially since I am not so structured where I can sit down for five hours for a standardized [test] and be completely focused.... It is just my attention span. I was never taught another way to fix my attention span.
As we probed the perceptions of a subpopulation of underrepresented minorities in medicine (i.e., black American male medical students and physicians) regarding contributors and barriers to their success in medicine, we noted similarities and differences with the findings of earlier studies. The findings were similar in that support, faith, mentorship, financial burdens, poor educational resources, lack of minority role models, difficulty with standardized testing, a desire to serve the community, and personal and family values were important factors in helping or hindering success.4,5,8,11–14
The differences found in this study relate to how the contributors and obstacles to success affect the individual. For example, Odom and colleagues15 noted that many minority medical students still experience significant barriers from perceived bias and discrimination in their interactions with peers, administrators, and faculty. The black men in our study recognized that bias and discrimination remain, but they did not believe that racism was an obstacle for them. The previously published results can be, in part, attributed to research methodology that included several racial/ethnic groups and women. In focus groups where there are different races, genders, and ethnicities, the discussion may be restricted to a “shared or common perception.” Our study focused only on black men. In addition, the interviewer was a black medical student, and one-on-one interviews prohibited a group-think mentality and, to a lesser extent, lessened the likelihood of shared and common experiences influencing the interview. On the other hand, our study had a small number of participants; a larger number might have included one or more black men who did believe that racism was an obstacle.
For our participants, support, education, exposure to the field of medicine, group identification, faith, and social responsibility contributed to their successes. These themes were significant to the interviewees' personal development and interacted with one another to influence the participants' successes.
Community, financial, and educational challenges, lack of social support, societal bias, and difficulties with standardized testing were considered obstacles to success. The net effect of the obstacles and contributors to success was in the positive direction leading to medical school matriculation and, in the case of the three physicians, graduation and clinical practice.
This cohort of black men made it to medical school because the challenges were met, obstacles surmounted, and contributors taken advantage of to result in an overall goal achievement. It may be helpful, however, to approach the findings of this and previous studies in light of a theoretical construct. The Spencer phenomenological variant of ecological systems theory (PVEST) is a thematic framework that demonstrates how individuals perceive, properly analyze, represent, and explain obstacles and contributors to success and depends on the individual's social and cultural context.16,17 PVEST takes an interdisciplinary approach, integrating psychological, ecological, and phenomenological models with an emphasis on self-appraisal processes.16,17 Because of this framework's consideration of the cultural interactions such as socioeconomic conditions (e.g., poverty), sociocultural expectations (e.g., race stereotypes), and sociohistorical events (e.g., discrimination) with the individual, it has been found helpful in the study of the success and resiliency of young black men.18
As demonstrated in Figure 1, the psychosocial–cultural context is defined by social support, family support, societal views, a sense of social responsibility, and personal group identification. Personal attributes, for example, work ethic, can modify and be modified by the social–cultural influences. At the same time, exposure to the field and educational phenomena can influence and interact with personal attributes.
Framing the interpreted themes within the construct of PVEST, four theoretical concepts can be identified: psychosocial–cultural influences, educational experiences, exposure to the field of medicine, and personal attributes and individual perceptions. Social support, family support, group identification, social responsibility, and societal views represent psychosocial–cultural influences. Education phenomena and exposure to the field of medicine are individual experiences that are not directly related to social or cultural phenomena, that depend on availability, and that are influenced by personal attributes such as motivation.
Metaphorically, one may picture the pursuit of success as a table. The legs of the table represent the four themes/domains that contribute to success and stability: exposure to the field of medicine, psychosocial–cultural factors, education, and the personal attributes or character of the participant that support the individual's ability to succeed. Depending on the presented experience and the individual's perception, the factor providing the foundation of the table may either strengthen or weaken personal success. For example, an interviewee reported that a high school teacher gave him negative feedback, telling him that he would succumb to the pitfalls, such as drug dealing and prison, as many of his inner-city peers did. This was a negative experience, with potential to weaken the educational and psychosocial–cultural support for ultimate success. However, the participant responded by motivating himself to prove that the teacher was wrong. The personal interpretation or response, in relation to social–cultural influences, allowed that participant to turn a challenge into a contributor to success. The interaction between personal attributes and other contributing factors served to lift him toward his goals, balanced and strengthened his resolve, and ultimately led to success.
It is important to provide black men with as many positive interventions as possible to facilitate positive outcomes. Depending on which leg of the table represents a potential deficit, a strategy must be implemented to strengthen that particular leg to increase the chance of success in medicine. The influence of one's personal attributes, as they relate to the other factors contributing to success, can provide the balance and support to overcome deficits in any one area. Strong and supportive experiences in education, meaningful exposure to the field of medicine, and strong support systems can reinforce the personal strengths of the individual so that reaching one's goals becomes reality (see Figure 1).
As developing youths spend the majority of their childhood and adolescence at school and in the community, opportunities in these environments can be used for positive outcomes. For example, proper faculty and staff training and development in secondary institutions are crucial in this collaborative effort. Many of the interviewees reported a strong desire to participate in high school athletics and recalled significant experiences with their coaches. Although some were positive (e.g., a coach cooperating with a student's educational endeavors, a coach facilitating teamwork), many were negative (e.g., quitting the football team because “coach didn't care about my grades, coach only cared about winning and not my personal life”). If athletics are popular choices for black men in secondary school, the coach has the access and responsibility to initiate positive experiences for these young men.
Ideally, one would desire to have a student's “table” have all its legs strong and supportive, providing a stable foundation to attain success regardless of the career chosen. This is not always the reality that students face. Families' structures are sometimes broken, social support is scarce in many communities, and the educational resources and quality of curricula are not accessible to all students. Yet, we also saw—as stated previously—that personal attributes such as motivation can help a student succeed even when conditions are not ideal.
Although many important issues were identified, our study has limitations. Although CQR methodology that pays particular attention to the minimization of biases was used by the investigators, individual bias and errors in interpretation of voluminous data were possible. This cohort was a convenience sample of black men in one medical school in one town. The interviewer did know a few of the participants, and that familiarity could have affected the interviews. The interviewer was an African American man, and therefore the participants could have responded differently than if the interviewer had not been racially similar. Although it is more likely that the group identification facilitated the interview, participants could have tempered their answers in an effort to please. Further research is therefore necessary to identify potential bias.
An increase in diversity in medical schools has been identified as an important step to addressing the needs of the diverse U.S. population.1 Black men continue to be a minority of minorities in medicine. This study confirms findings from previous studies and, more important, shows that success is a complex interaction between environmental phenomena and the individual. Outreach and “pipeline” programs have generally concentrated on the four “legs” of success: exposure to the field of medicine, psychosocial–cultural factors, education, and the personal attributes or character of the participant.19–22 The results of this study support that approach but also provide a theoretical construct that can be used by programs, medical schools, and curricula to improve the success of black men in medicine as well as generate future quantitative studies. Further research is necessary to determine factors for success for black women in medicine.
The authors would like to thank Myra Williams for her efforts with the study and manuscript preparation.
This study was approved by the Florida State University human subjects committee.
The results of this study were presented at the 16th Annual Rural Multiracial and Multicultural Health Conference, December 1–3, 2010, Tucson, Arizona.