We can’t make things better until we acknowledge how things are.
–Kim McLarin, Modern Love Podcast1
Although academic medicine cultivates a culture supportive of discovery and innovation,2 this esteemed legacy is also fraught with a history of elitism, racism, and sexism. There was a time in medicine where women’s involvement was merely to assist White male physicians,3,4 and African Americans were prodded as specimens for the literal purpose of “practicing” medicine.5–9 This past contributes to lingering unconscious biases and daily cues within the academic medicine environment today, which continue to permeate and persist in the form of the exclusion of women and those from racial/ethnic backgrounds underrepresented in medicine (URM). Ultimately, exclusions impede health care workforce progress and will continue to do so if not truly acknowledged and strategically addressed through initiatives that intentionally foster a sense of belonging and ensure that women and URM groups are seen, heard, and valued in academic medicine environments.
Rising Numbers in Medical School
A physician workforce that is representative of the general U.S. population improves the quality of health care.10 However, achieving racial/ethnic11–13 and gender14 representation in the medical workforce has been a slow process, which for some groups has stalled. There has only been a 1.1% increase in African American matriculants from 1980 to 2016.15 Within this group, African American female matriculants’ growth has outpaced that of their African American male counterparts,16 although there has been a recent uptick in enrollment among the latter group.17 However, when analyzing population growth among racial/ethnic groups that are URM, medical schools still fall short of achieving representative levels of racial/ethnic diversity.18
As for gender parity in medical school admissions, there has been more substantial progress with women comprising more than 50% of U.S. medical school applicants and matriculants in 2018.19 Despite this, Raj and colleagues draw attention to the critical need for additional interventions to ensure that trends in the gender composition of medical students translates into parallel parity in access to career opportunities.20 However, addressing issues related to gender representation may not necessarily lead to progress in improving racial/ethnic representation and vice versa.
Not All Boats Rise: Race, Gender, and Academic Medicine
In graduate medical education training, representation of women and persons from URM racial/ethnic groups varies among specialties. Among the 20 largest specialties, only 7 specialties had women entering at proportions of 50% or more in 2012, even though women were nearly 50% of the graduating medical student class that year.21 As for African Americans, none of the largest specialties had representative percentages in 2012.21 In 2015, women represented nearly 40% of full-time faculty at U.S. medical schools, while full-time non-White women accounted for only 11% of this 40%.22 African American and Hispanics academics are underrepresented in nearly all specialties and in all ranks outside of instructor or lecturer, with overall percentages declining over time.18 In 2014, women were 14% of all department chairs in U.S. academic medical centers, with non-White women representing only 3% of this 14%.22 Thus, the academic potential of women and physicians from URM racial/ethnic backgrounds fails to be captured at a variety of levels.
Lived Experiences of Women and URM Persons
Multiple challenges undermine the confidence and sense of belonging of women and URM persons. The National Science Foundation has drawn attention to the alarming rate of sexual harassment of women in academic medicine relative to other professions, underscoring that women from URM racial/ethnic groups are at even greater risk of being targeted.23 Microaggressions, which Sue and colleagues define as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional,”24 in the workplace can send subtle insults to both women25 and URM persons26 and contribute to feelings of inferiority.
How do these exclusionary experiences show up?
Discriminatory patient behaviors
First, interactions with patients may serve as reminders to women and URM persons that they do not “fit” in medicine. For women and URM physicians, patients may express skepticism when they see someone who does not match their expected visual criteria for a physician. In October 2016, the online social movement, #WhatADoctorLooksLike, was spurred by a Black female physician who was dismissed when offering to assist during an in-flight emergency in favor of a White male on board who was presumed to be a physician.27 URM physicians may be outright denied from participating in the care team due to a patient’s repugnant racist demand28 or other discriminatory behaviors based on perceived country of origin.29 Cumulatively, subtle microaggressions and more overt forms of discrimination add up to strong messages of exclusion. The negative impact of these messages contribute to what Walton and Cohen described as “belonging uncertainty,” which is when persons who are made to feel marginalized in the academic and professional setting wonder about their belonging, feel disconnected, and ultimately experience reduced motivation and achievement.30
Fewer mentoring opportunities
Second, access to mentoring may be limited. Despite the relatively novel presence of women and URM physicians, which can make them stand out in academic medicine, there is some evidence that they may be overlooked within the academic environment, particularly for mentoring opportunities. Milkman and colleagues studied differences in access to such opportunities by sending identical emails—other than the sender’s gender and race/ethnicity—inquiring about research opportunities to over 6,500 professors across 89 disciplines.31 They found, irrespective of the professor’s demographics, the emails sent from White male students were more likely to get responses than those written by women or racial/ethnic minorities.31 Mentors also have been found to gravitate toward the “rising star” protégé, a person who has high expectations for career advancement, is engaged in proactive strategies, and has a strong promotional history.32 As women and URM physicians continue to strive to acculturate into academic medicine, they may not typically be viewed as a coveted rising star, even though they may be more likely to benefit substantively from mentorship. Women and URM physicians are judged differently, as evidenced in their clerkship experiences33,34; various evaluations, including the Medical Student Performance Evaluation35–38; and rates of entrance into medical honor societies.39 Some academic physicians, regarded as knowledgeable role models, shared their reluctance to acknowledge race or gender when mentoring diverse trainees.40 Conversely, African American residents shared a desire to integrate their racial identity with their professional role.41 In other qualitative studies of racial/ethnic minorities in medicine, students described experiences during their training in which their racial/ethnic identity made them feel isolated or ignored on rounds and/or in the classroom34 and faculty reported feeling invisible in the workplace.42,43 Taken together, this means that when women and URM physicians attempt to connect with and build their academic social network by seeking mentorship, both populations can have limited prospects. It is not surprising then that women and those from URM racial/ethnic backgrounds may be more likely to experience imposter syndrome (i.e., an internalized feeling or fear of being a fraud despite evidence indicating success).44,45 This likely also contributes to women and URM physicians not feeling like they belong, as Walton and Cohen posit that those who question their belonging are sensitive to cues that reinforce their sense of not belonging and are skeptical of disaffirming cues.30
Culture of exclusion
Third, within academic medical centers, institutional messages can further perpetuate a culture of exclusion. Imagery representing the “traditions of medicine” are found on the walls of the hospital and throughout the medical school. These looming physician portraits represent those who have greatly contributed to the field, and the contributions of women and URM physicians are often visibly absent. Images that do include racial/ethnic minorities usually do not portray these individuals in positions of authority, but rather as the recipients of White physicians’ care. Cheryan and colleagues found that items in the physical environment can reinforce stereotypes about who belongs (i.e., ambient belonging) and serve as “gatekeepers” to others who are not able to easily identify their connection to and value within the academic environment.46 Aspiring URM physicians arrive eager to contribute and introduce their ideas but often find that their visions for their medical careers are incongruent with and/or undervalued in the academic space. For example, African American medical students’ perceptions of success have been explored; these students described valuing “giving back to their families and to the community” more than their White peers,34 which is counter to the individualistic mindset encouraged throughout academia.
To Be Seen, Heard, and Valued
It is possible to shift the norms in medicine and the course of historical exclusion. However, it will require a shared awareness among faculty, administrators, and trainees to develop intentional strategies to alter individual behaviors, academic spaces, and institutional processes to cultivate a sense of belonging. Furthermore, faculty development is essential to provide mentors, educators, and leaders with tactical strategies to intercept and address exclusionary behavior and to develop cross-cultural relationships.
Providing faculty skill development for cross-cultural mentorship
Bickel and Rosenthal underscored the importance of faculty having strong communication and leadership skills to facilitate discussions on sensitive or difficult topics traditionally deemed “undiscussable” that arise when forging cross-cultural relationships.47 White mentors’ reluctance to discuss the influence of racial/ethnic identity in the workplace (i.e., protective hesitation) adversely affects the career development of racial/ethnic minority mentees.48 Although having a role model that “looks like you” is critical, there is an essential role for allies. URM trainees were found to perceive benefit from mentorship from non-minorities, as it engendered feelings of acceptance within the larger professional community.41 Therefore, getting comfortable first and foremost with talking about medicine’s exclusionary history is critical. Creating space to be able to speak collectively with colleagues, residents, and medical students about the intersection of their personal—including racial/ethnic and gender—and professional identities is a clear step forward. Future research is needed to illuminate what other behaviors sustain meaningful mentoring relationships across identities.
Creating inclusive spaces
Administrators should take stock of their institutional messages (e.g., portraits on the walls, website, marketing campaigns) and aim to design welcoming spaces that balance the contributions of the past with the evolving contributions of women and URM persons. Symbolism and imagery are much more important to a sense of belonging than they are often perceived to be. This includes the images that adorn the halls49 but does not end there. This also relates to messages promising a commitment to diversity and equity. For example, many well-intentioned institutions promote diversity activities. However, minority and nonminority trainees may find that further discussions are held in the shadows or solely within racial/ethnic affinity groups. It is important to avoid tokenizing (e.g., highlighting a minority or diversity-related event to merely give the appearance of diversity) because inauthentic attention and action is more likely to result in further disillusionment than to placate. Teaching tools such as inclusive practices (i.e., those that pay attention to social identities and learning environments that perpetuate inequities)50 and cross-cultural case studies51 can be thoughtfully integrated into all phases of undergraduate and graduate medical education to navigate discussions about race/ethnicity.
Rethinking productivity metrics
Finally, and importantly, there should be renewed attention given to the metrics of productivity in academic medicine. With the shift in physician workforce demographics come new perspectives, career aspirations, and concepts of how to have a meaningful impact. Meaning and purpose may be spurred through efforts to “give back” to the community or provide outreach (e.g., mentoring, community-level leadership). Academic institutions may find it challenging to quantify the impact of these types of activities and fail to appreciate the benefit that community connection has for URM physicians. However, capitalizing on a person’s drive to improve the health of and maintain a connection to their community could spur innovation and advances in health care equity if encouraged to flourish. Thus, it would be in academic institutions’ interest to develop mechanisms (e.g., community outreach fellowships, institutional grants) that foster and capture excellence in community involvement in productivity metrics.
In conclusion, academic medicine environments must change so that women and URM racial/ethnic groups are seen, heard, and valued. However, this requires that academic medical centers pull back the veil to face the reality that indignities encountered “out there” in the broader society color the daily experiences of women and URM physicians “in here.” As women and URM physicians continue to integrate into the medical field, so do their gender and racial/ethnic identities. It will be important for academic environments to acknowledge the intersection of personal and professional identities and the negative and positive effects these can have on their experiences and access to opportunities. Careful attention must be paid to the classroom and clinical environments to identify behaviors or practices, whether implicit or explicit, that undermine workforce diversity efforts. This is a critical step in developing targeted strategies to counter exclusion to create inclusive environments and a true sense of belonging.
The author wishes to thank Drs. Becky Wai-Ling Packard and William Barsan for their mentorship and support in the development of the original presentation and panel discussion. The author also thanks Dr. Packard for her encouragement to transform the presentation into a manuscript.
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