In 1978, 542 Black men matriculated into medical school in the United States.1 In 2014, the number was 515.1 This negative trend was only found in Black men and American Indian/Alaska Native groups.2 Since then, there have been efforts by medical schools to mitigate some of the challenges faced by underrepresented minority (URM) and first-generation physicians.2,3 Initiatives include tuition-free medical education and increasing diversity in the classroom.2,3 Others have made a concerted effort to take a more holistic view of candidates, taking into account their socioeconomic and geographic background.2,4,5
Challenges for Black men and women start as early as grade school; many people of color grow up in impoverished areas and attend underfunded primary schools, leading to a lag in academic development.6,7 A study by Polite and Davis8 found that at the time of high school graduation, only 1 out of 15 Black men in their sample were prepared for college. Black men enroll in college at lower rates than Black women and graduate at lower rates as well.6 Furthermore, children living in impoverished communities often face threats of violence, early encounters with the justice system, and multiple other factors that make applying themselves solely to education difficult.9 These factors are often thought to impact Black men at higher rates than women, thereby contributing to the disproportionate lack of Black men entering medicine.
Another challenge is paying for higher education.1–3 In 2017, the average medical school debt was $192,000.10 Because many Black men are relied upon to help support family finances, they may be encouraged to pursue careers with quicker pathways to generating income. This financial urgency in combination with the large debt burden of medical school leads some to conclude a career in medicine is unreasonable for their circumstances.
As the United States becomes more diverse, we must consider the implications of diversity within the medical workforce. By the year 2043, the nation will no longer have a “majority” ethnic group.11 A 2017 study by the National Bureau of Economic Research demonstrated that Black men who had Black primary care physicians were 18% more likely to adhere to their doctor’s preventative health care recommendations when compared with those assigned to physicians who were not Black.12 It is hypothesized that this outcome is due to improved communication between providers and patients because of better cultural understanding.12 Studies have also shown URM physicians may be more willing to work with URM and low-socioeconomic-status patients.13 The majority of URM (53.5%) and 70.4% of non-English-speaking patients in the United States were cared for by URM physicians, exhibiting that URM physicians tend to be more willing to work with poor and URM patients.13
In 1944, Gunnar Myrdal14 wrote that Black–White differences were arguably America’s biggest problem. Unfortunately, this problem remains. When compared with their White male counterparts, the life expectancy of Black men is notably lower.15 This disparity has been attributed to diseases such as diabetes mellitus, hypertension, and chronic kidney disease—most of which are preventable and controllable with proper medical care. Increasing diversity in medicine could contribute to a decrease in such disparities. In this paper, we detail some of the challenges faced by Black men in medicine and propose how effective mentoring can help Black men prepare for, matriculate through, and succeed in medical school and beyond.
Unique Challenges Encountered by Black Men in Medicine
Beyond the medical field, it is generally agreed that Black men are under increased societal pressures.16 In the following section, we delineate 3 challenges encountered by Black men in medicine.
The ambassador role
Across disciplines and during all stages of life, URMs serve in “ambassador roles” for their race.17 It is estimated that Black men and women account for only 6% of medical doctors and, as a result, they may feel the need to represent their entire race.5 Osseo-Asare et al17 wrote about the struggle of being a minority resident physician and the extra challenges they face. The authors allude to what is often referred to as the “Black” or “minority” tax, which suggests that URMs are “taxed” with extra responsibilities as a result of their unofficial ambassador role. They noted that URMs were called upon to fix the “minority problem,” take on an extra burden to care for minority patients, or start minority-focused initiatives.17 To complicate the matter, these medical professionals felt they lacked the necessary support to accomplish their already assigned tasks.
Another challenge faced by Black men in medicine is “double consciousness,” a phrase coined by the Black intellectual W.E.B. Du Bois. Du Bois’ concept is that Black individuals are in a constant state of tension as they navigate between the individual who people expect them to be, based on their race and American history, and who they truly are.18 For example, a Black physician may introduce himself to a patient who then questions whether or not he is the only doctor they will be seeing and if they can see someone else instead. The patient, for whatever reason, may feel the physician is not as well qualified as other doctors, causing the physician to contend with the patient’s view of him while also understanding that he is qualified to be in the position.
The constant strain of double consciousness can lead to a third challenge: racial fatigue. This fatigue occurs in an environment where race is a constant underlying theme that is never addressed.19 For Black men, in particular, perpetual negative stereotypes and constant inaccurate perceptions incrementally contribute to racial fatigue. An example of racial fatigue is the myth that there are more Black men in prison than in college.1 Internalization of this construct and the continuous struggle to reverse this perception can be fatiguing and adversely affect performance.1
We contend that the combination of these 3 stressors—ambassador role, double consciousness, and racial fatigue—contributes to the burden of being a Black man. In academic medicine, a field where few Black men exist, these burdens become real stressors that can negatively impact career progression and well-being.20
Special attention to this crisis is needed to reverse the negative trend of low matriculation rates among this demographic. One approach is to study the specific attributes of individuals who have successfully matriculated through medical school. In 2010, Thomas et al21 examined the characteristics of Black men who matriculated into Florida State College of Medicine (FSUCOM), graduated from FSUCOM, or were practicing physicians in the surrounding county. They identified 6 categories that contributed to the success of their study population: (1) social support, (2) education, (3) exposure to the field of medicine, (4) group identity, (5) faith, and (6) social responsibility. In the subsection of social support, a majority of the participants listed having a mentor as a key factor in their success in the field of medicine. This listing comes as no surprise given the well-documented benefits of mentorship in career development.21,22
Importance of mentorship
In 2006, Sambunjak and colleagues23 published a systemic review on mentoring in academic medicine. They identified 5 studies in which mentors were noted to be a career-enhancing factor.24–28 One study of obstetrics–gynecology fellows found that those who had a mentor were more likely to eventually achieve promotion to professor compared with those who did not have a mentor.26 The authors concluded that mentorship positively impacts personal development, career choice, and research productivity.23 Other studies have suggested a lack of mentorship hinders career progression. Jackson et al29 noted 98% of academic clinicians reported lack of mentorship was the first or second most important factor hindering progress in academic medicine. Appreciating this, it is unfortunate that URM in medicine receive less mentorship than their majority counterparts.20
Challenges to Mentoring Black Men in Medicine (RACE)
To assist mentors in overcoming obstacles that may inhibit their mentoring relationships with Black men pursuing advancement in medicine, the authors developed the RACE framework, which covers: Reluctance to discuss race, Access to mentors, Cultural mistrust and Racial concordance, and Empathy.
Reluctance to discuss race
Historically, the academic community has been reluctant to engage in discussions about race. Sue identified societal “rules” that discourage racial dialogue in mentoring, especially in academic settings.30 These rules are:
- “The politeness protocol,” which states difficult topics should either not be spoken about or only in a very superficial manner.
- “The academic protocol,” which discourages emotions when discussing topics, and because of the charged discussion that surrounds racial discussion, they are avoided in the academic environment.
- “The color-blind protocol,” which is the idea that racial differences are only skin deep and so there is no need to acknowledge racial differences in an organization.
In academic medicine, these protocols can result in silence when non-URMs are challenged to engage in conversations involving race.31 Acosta et al32 reported that health professions students desire that their faculty engage in more difficult conversations on race. One such conversation could address, for example, the belief, which many medical students still hold, that people of certain races or ethnicities have different thresholds for pain. Some faculty do not feel comfortable or adequately trained to have these conversations.32 Having a mentor who has insight into racial biases in patient care, both conscious and subconscious (or implicit), can benefit mentorship of the URM student and facilitate professional development.33 On the contrary, lack of insight into racial considerations or protective hesitation by the mentor can limit effective mentoring of the URM trainee.
Cross-cultural mentorship between Black men and individuals from other backgrounds, including honest and open discussions of race, can bridge historical, contemporary, and cultural differences to establish a trusting relationship between a mentor and mentee.34 The authors believe that these cross-cultural exchanges not only help the mentor–mentee relationship but also help the mentor learn more about different cultures and improve their patient care.
Access to mentors
Finding a mentor can be challenging regardless of an individual’s race; however, it may be a greater task for URMs and Black men in particular. The mentoring relationship is bidirectional, and because of this, not only do mentees desire to have mentors who are like them but also mentors often have the same desire for their mentees. With so few Black physicians, this presents a unique challenge as it can be difficult for Black men to find mentors of similar racial backgrounds.1 This truth underscores the significance of establishing intentional mentoring programs focused on increasing access to mentors for Black men pursuing medical careers.
In general, there are 2 types of mentoring programs focused on URMs interested in medicine. We consider the first type to be extramural and community based. These programs are typically linked with major universities and focus on mentoring precollege individuals by hosting community events and establishing mentoring opportunities. It has been the authors’ experience that such programs are scarce in existence. Furthermore, many of them prove to be short lived because of inadequate oversight. An example would be a mentoring program established between medical students and students at a local elementary school. Not infrequently, these programs are driven by 1 or 2 individuals who are passionate about mentoring, but once these individuals graduate, the program dissolves.
The second mentoring program category, intramural, is more familiar to academic medicine. These are typically coordinated by a designated staff member within a medical school diversity office or by an officer of a student organization. Often, intramural programs have more resources and are more formal than extramural programs. Their main objective is to pair mentors with mentees within a single academic center. While there are challenges, such as enforcing communication between mentors and mentees, such programs can play a critical role in providing access to mentorship.
Cultural mistrust and racial concordance
Perhaps more important than any other facet in the mentoring relationship is trust. A mentee needs to trust that their mentor has their best interests in mind. A mentor must trust that their mentees will value their guidance and make the most of their time. Unfortunately, historical events in the medical field have introduced a certain level of mistrust. As it pertains to Black men specifically, the Tuskegee Study of Untreated Syphilis in the Negro Male35,36 is an example of sentiments of mistrust that persist. Though this example is not directly related to medical education and career development, the notion of Black men being “less than” to such an extent that they were experimented on resonates with Black men regardless of their profession. For some mentees, feelings of mistrust can lead to a defensive relational state when interacting with physician mentors of the majority race and gender. In such situations, trust must be earned before the mentee can freely accept the guidance of that mentor.
One strategy to build trust in a mentoring relationship is for both parties to establish expectations early in the process. An example of such an expectation is the length of time that a mentor or mentee has to respond to the other. In doing this, the mentee has mutually agreed-upon standards that he can now use as a rubric for building trust, which is required for the relationship to flourish.37
In 2014, Yehia et al38 evaluated the mentorship of medical residents from diverse backgrounds. They noted a desire of African Americans, Hispanics, and women to identify mentors of the same race/gender. Reportedly, a lack of racial concordance between the mentor and mentee presented an obstacle for the URM trainees. Specifically, these mentees felt they had to explain their culture to their mentor in some situations.38 While the constant need to explain one’s cultural perspective in a racially discordant relationship can be emotionally taxing, developing this understanding plays a critical role in the mentorship process.
Noting the aforementioned, an important question presents itself: Does a successful mentoring relationship necessitate racial concordance? While no randomized studies have demonstrated superior effectiveness of mentor–mentee relationships with racial discordance, there is anecdotal evidence supporting its usefulness.34,39 From a practical perspective, the authors believe that in certain circumstances, having a mentor in your specific area of interest may be as important, if not more important, than the race of the mentor.
The Merriam Webster Dictionary defines empathy as “the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner.”40 The key phrase in this definition is “vicariously experiencing.” To best guide an individual, a mentor must be able to put themselves in the shoes of their mentee. The ability to do this makes it easier to understand a mentee’s wants and needs.
Achieving empathy for Black men can be challenging given their complicated history in America. The difficulty lies in others being able to relate to the deeply rooted emotions that certain circumstances may generate in Black men. For example, the belief that many Black men feel uncomfortable in environments with police officers; while other people may be uneasy in similar situations, their feelings may not lead them to fear for their lives as happens for some Black men.41 Anecdotally speaking, this fear can permeate into all areas of life and, subsequently, influence behaviors in various arenas, ranging from the supermarket to the hospital. Understanding this difficulty in achieving empathy for Black men, certain individuals may be reluctant to engage with them as mentors.
It should be noted that the empathy challenge is quite different from that of cultural mistrust and racial discordance. Lack of trust is primarily prohibitive to the mentee being receptive to guidance. If he or she does not believe the mentor has their best interests in mind, they will not value the relationship. On the other hand, lack of empathy hinders the mentor’s ability to provide individualized and appropriate guidance. Without an understanding of the mentee’s affective state, the mentor may struggle to understand their choices. Ultimately, for a mentoring relationship to succeed, the mentor must be willing to narrow the empathy gap.
Conclusion and Recommendations
The lack of Black men in the medical field is a crisis demanding immediate attention from academic medicine. While a great deal of attention has been focused on increasing diversity in medicine, only in recent years has the field of medicine taken note of this issue and begun to mobilize resources toward a solution. Among the low-hanging fruit of approaches that would help increase the number of Black men in medicine is strategic and organized mentorship for this demographic. Black men are underrepresented in medicine and face unique obstacles. The guidance of a good mentor can be critical to individuals from all backgrounds; however, given the current situation of Black men in medicine, the impact for this group has the potential to avert a national crisis. To achieve this, a strategic mentoring approach for Black men is needed.
We contend that this approach must address the 4 key elements of the RACE framework: Reluctance to discuss race, Access to mentors, Cultural mistrust and racial concordance, and Empathy. In considering these, we conclude that: (1) Honest racial discussions are essential to a successful mentoring relationship; (2) Intentional effort must be made to identify and assign mentors to Black men in the medical field; and (3) Racial concordance between mentor and mentee is not a requirement for a successful relationship.
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