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The Effects of Racism in Medical Education on Students’ Decisions to Practice in Underserved or Minority Communities

Phelan, Sean M. PhD, MPH; Burke, Sara Emily PhD; Cunningham, Brooke A. MD, PhD; Perry, Sylvia P. PhD; Hardeman, Rachel R. PhD, MPH; Dovidio, John F. PhD; Herrin, Jeph PhD; Dyrbye, Liselotte N. MD, MHPE; White, Richard O. MD, MSc; Yeazel, Mark W. MD; Onyeador, Ivuoma N. PhD; Wittlin, Natalie M. MS, MPhil; Harden, Kristin MPH; van Ryn, Michelle PhD, MPH

doi: 10.1097/ACM.0000000000002719
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Purpose The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students’ intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation.

Method The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students’ intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students’ practice intentions (no/undecided/yes) at matriculation.

Results Students’ more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students’ perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients.

Conclusions This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students’ decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

S.M. Phelan is associate professor, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota.

S.E. Burke is assistant professor, Department of Psychology, Syracuse University, Syracuse, New York.

B.A. Cunningham is assistant professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota.

S.P. Perry is assistant professor, Departments of Psychology and Medical Social Sciences, Institute for Policy Research, Northwestern University, Evanston, Illinois.

R.R. Hardeman is assistant professor, Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.

J.F. Dovidio is professor, Department of Psychology, Yale University, New Haven, Connecticut.

J. Herrin is assistant professor, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.

L.N. Dyrbye is professor, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

R.O. White is assistant professor, Department of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida.

M.W. Yeazel is professor, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota.

I.N. Onyeador is postdoctoral fellow, Department of Psychology, Yale University, New Haven, Connecticut.

N.M. Wittlin is a PhD candidate, Department of Psychology, Yale University, New Haven, Connecticut.

K. Harden is senior program coordinator, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota.

M. van Ryn is distinguished professor, School of Nursing, Oregon Health & Science University, and founder/president, Institute for Equity & Inclusion Sciences, Portland, Oregon.

Funding/Support: Support for this research was provided by the National Heart, Lung, and Blood Institute under awards R21HL135070 and R01HL085631.

Other disclosures: None reported.

Ethical approval: The institutional review boards at the Mayo Clinic and the University of Minnesota approved this study.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A659.

Correspondence should be addressed to Sean M. Phelan, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905; telephone: (507) 266-4885; email: phelan.sean@mayo.edu.

© 2019 by the Association of American Medical Colleges