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Research Reports

Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms in Black U.S. Medical Students

Milam, Adam J. MD, PhD1; Brown, Italo MD, MPH2; Edwards-Johnson, Jennifer DO, MPH3; McDougle, Leon MD, MPH4; Sousa, Aron MD5; Furr-Holden, Debra PhD6

Author Information
doi: 10.1097/ACM.0000000000004638

Abstract

Race and ethnicity significantly modify the experience of undergraduate medical education. 1,2 Structural and systemic racism underscore elements of the medical curriculum, influence recruitment and retention of underrepresented minority students and faculty members, and introduce sociopsychological stressors that are disproportionately experienced by students of color. 3 For Black students, these daily occurrences have mental and physical consequences. 4

Furthermore, for Black medical students, the legacy of racial trauma predates their acceptance letters. In 2020, that legacy of trauma and racial injustice shifted from an underaddressed issue to a national public health concern. 5 The murders of Ahmaud Arbery, George Floyd, and Breonna Taylor accelerated an existing social justice movement in the midst of a global pandemic. 6,7 Medical students found themselves at the intersection of health inequity and social injustice, both of which have been driven by long-standing structural racism. Racial unrest can have a vastly different impact on Black medical students than on White medical students, and so far, the effects of increased exposure to race-based trauma have been incompletely explored in this population.

The impact of race-based trauma (i.e., the stress caused by racism) has, however, been examined in the general population. 8 Witnessing and experiencing race-based trauma have a substantial impact on the health and well-being of minority populations. 9–11 In a study examining the relationship between exposure to traumatic race-related events online (e.g., seeing images or videos of someone from your racial or ethnic group being arrested, detained, or shot by police) and depressive symptoms among a sample of 302 Black and Latinx/Hispanic adolescents, Tynes and colleagues 9 found that more frequent exposure to such traumatic raced-related events online was associated with more depressive symptoms. At a population level, witnessing race-based trauma has important mental health ramifications. For example, Das and colleagues 12 found that police killings of unarmed Black individuals were associated with an 11% increase in emergency department visits for depression among Black persons up to 3 months later. However, the authors did not find a relationship between the killing of armed Black individuals and emergency department visits for Black persons, suggesting that racism can play a role in the development of mental health symptoms.

The weathering hypothesis and the race-based traumatic stress injury model provide some insight to understanding the relationship between race-based traumatic events and mental health problems. 8,13 Cumulative stress, whether subjective (e.g., perceived discrimination) or objective, is at the core of both; the weathering hypothesis suggests accelerated biological aging among Black persons secondary to cumulative exposures to stress, 8,13,14 and the race-based traumatic stress injury model describes the emotional pain and reaction to racial encounters perceived as extremely negative and uncontrollable. 8 Black persons may face more social stressors compared with White persons; the byproduct is a shorter life expectancy and increased morbidity for Black individuals. 15,16 Various studies demonstrate that Black medical students experience higher degrees of stress, depression, and anxiety than their non-Black counterparts. 17,18 While wellness initiatives have recently become standard for undergraduate medical institutions, the efficacy of these resources among Black medical students as well as whether they have been equitably distributed to Black medical students have not been well studied.

Beyond general wellness initiatives, institutions have attempted to respond to events that significantly alter the cultural landscape and national conversation around race (i.e., seminal race events). 19 Responses to these seminal race events by undergraduate medical institutions fall on a spectrum, ranging from initiatives that prioritize diversity, equity, and inclusion to formal statements on antiracism. 20,21 It is also customary for medical schools to offer support services for students experiencing emotional trauma related to seminal race events. These events can cause new emotional trauma and trigger previous emotional trauma, particularly for students who identify as Black. 22 Whether the responses and support services provided by institutions are sufficient or culturally appropriate, however, remains unclear, and we were unable to identify any quantitative studies that have examined the relationship between institutional responses to seminal race events and mental health outcomes among medical students.

Accordingly, the current study examined the relationship between institutional responses to seminal race events and depressive symptoms among Black medical students. We also examined how experiences of racial discrimination may moderate this association. Given gender differences in depression and risk factors for depression, 23 we explored gender as a potential moderator between the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms. We hypothesized that the lack of institutional responses to seminal race events and experiences of racial discrimination would be associated with more depressive symptoms among Black medical students. Additionally, we hypothesized that experiences of racial discrimination would have a positive synergistic effect on the relationship between the lack of institutional responses to seminal race events and depressive symptoms.

Method

Overview

This study uses data collected from a convenience sample (i.e., nonprobability sampling) of Black U.S. medical students via an anonymous 37-item electronic questionnaire (Qualtrics, August 2020, Qualtrics, Seattle, Washington; see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B240). 24,25 The survey was open for 2 weeks in August 2020. The survey included questions on demographics, institutional responses to seminal race events, experiences of discrimination, and depression and anxiety. This study was determined to be exempt by the institutional review board at Michigan State University.

Procedures

The survey was distributed through the Student National Medical Association (SNMA) listserv. The SNMA, which was established in 1964, is a national, student-run organization focused on supporting underrepresented minorities in medicine. The SNMA has 196 local chapters within medical schools and undergraduate institutions at historically Black colleges and universities as well as predominantly White institutions. The SNMA listserv has been used in recently published studies focused on microaggressions among minority medical students. 26,27 In addition, the survey was distributed to leaders of the Organization of Student Representatives (OSR) of the Association of American Medical Colleges (AAMC) via the OSR listserv. The OSR is an auxiliary branch of the AAMC that serves to incorporate students into the governance of the AAMC and facilitate student action on health care issues. Finally, posts on one of the authors’ (A.J.M.’s) social media accounts contained a link to the survey, requesting that only current medical students complete the survey. Students were advised that participation in the survey was voluntary and completed a consent form at the start of the survey. All participants received a $10 Amazon gift card upon completion of the survey.

Measures

Depressive symptoms.

The Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Short Form 8a was used to measure symptoms of depression. 28–30 This form includes 8 statements scored on a 5-point Likert-type scale (where 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always) that assess depressive symptoms over the past 7 days (e.g., “In the past 7 days, I felt hopeless”). The total possible range for raw scores on this form is 8 to 40. The raw scores were transformed to t scores based on the U.S. general population, with a mean of 50 and a standard deviation of 10. A t score of less than 55 = none to slight depression, 55–59 = mild depression, 60–69 = moderate depression, and 70 and above = severe depression. The PROMIS scale has been validated for use with adults and children and has acceptable validity and reliability. 31 The Cronbach’s alpha for this scale in the current study was 0.93.

Experiences of discrimination.

The abbreviated version of the Chronic Work Discrimination Survey created for the Chicago Community Adult Health Study was used to assess discrimination experiences. 32 This discrimination survey was adapted from the Perceived Racism Scale. 33 The survey includes 3 items (e.g., “How often are you unfairly humiliated in front of others at school?”) scored on a 5-point Likert-type scale (where 1 = once a week or more, 2 = a few times a month, 3 = a few times a month, 4 = less than once a year, and 5 = never). The total possible range for the experiences of discrimination was 3 to 15. The Cronbach’s alpha for this scale in the current study was 0.78.

Institutional responses to seminal race events.

Four items were used to measure institutional responses to seminal race events. The first item, “My institution responds to seminal race events that largely implicate Black individuals,” was answered on a 5-point Likert-type scale (where 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always). The remaining 3 items were binary response items (yes/no, where yes = 1 and no = 0): (1) “Did your institution respond to the death of Ahmaud Arbery?,” (2) “Did your institution respond to the death of George Floyd?,” and (3) “Did your institution respond to the racial disparities in COVID-19 deaths?” These items were reverse coded to indicate a lack of response by institutions. The total possible score for all 4 items ranged from 1 to 8. The Cronbach’s alpha for this scale in the current study was 0.61. Given the lower Cronbach’s alpha for this scale, we also modeled this scale as a latent variable using confirmatory factor analysis; the institutional responses to seminal race events factor had acceptable fit indices (comparative fit index [CFI] = 0.99, Tucker-Lewis index [TLI] = 0.96, root mean square error of approximation [RMSEA] = 0.84, weighted root mean square residual = 0.81). Additionally, the factor loadings were generally within the acceptable range (> 0.65).

Statistical analyses

Descriptive statistics were assessed; numbers and percentages were used for categorical variables and means and standard deviations were used for continuous variables. We also stratified these variables by gender, using chi-square analysis and t tests to assess differences. Path models in Mplus 7.3 (Muthén & Muthén, Los Angeles, California) were used to examine the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms among Black medical students. Model 1 adjusted for gender and a clinical diagnosis of depression or anxiety before medical school. Model 2 added an interaction term between experiences of discrimination and institutional responses to seminal race events (using the Xwith command) to identify potential synergistic effects between the 2 latent variables. Model 3 examined gender as a potential moderator by adding (to model 1) interaction terms between gender and experiences of discrimination and between gender and institutional responses to seminal race events (using the Xwith command). RMSEA, CFI, and TLI were used to assess model fit. RMSEA values ≤ 0.05, CFI values ≥ 0.95, and TLI values ≥ 0.90 generally represent a good fit to the observed data. Standardized estimates (standardized using the variance of the outcome variables, in addition to the variance of continuous latent variables) are presented below. P values < .05 were considered significant.

There were 933 students in the dataset; 750 students completed the survey for a completion rate of 80.4%. Of the 750 students completing the survey, 733 (97.7%) reported they were Black. Of the 733 Black medical students who completed the survey, 684 (93.3%) had no missing data (completion rate with no missing data, 684/933 = 73.3%). There were no differences between the Black participants with no missing data and those with missing data (n = 49) in terms of demographics or depression or anxiety t scores (P > .05). Mplus uses full information maximum likelihood to compute parameter estimates for cases with missing data, using all available data, and assumes that data are missing at random.

Results

Table 1 displays the descriptive statistics of Black participants. The sample was 80.5% (n = 586/728) female, and 56.1% (n = 405/722) of participants were in their first or second year of medical school. The majority of students (484/723, 66.9%) reported they had to work twice as hard as others to get the same treatment or evaluation, and 51.6% (n = 371/719) reported they were watched more closely than others (i.e., they answered that they experienced these a few times a month or more). There were no significant gender differences in the 3 questions used to assess experiences of discrimination (P > .05). Female medical students were more likely than males to report that their institution did not respond to racial disparities in COVID-19 deaths (261/584, 44.7% vs 49/140, 35.0%; P = .03), but there were no statistically significant gender differences in the remaining questions assessing institutional responses to seminal race events. Only 13.1% (n = 96/733) of students reported a clinical diagnosis of depression or anxiety before medical school. The t score for depressive symptoms was higher among females than males, approaching the range for mild depression (mean = 54.0 [standard deviation = 7.8] vs mean = 52.1 [standard deviation = 7.9]; P = .01).

T1
Table 1:
Black U.S. Medical Students’ (n = 733) Descriptive Data on Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms, August 2020a

Model 1 examined the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms, controlling for gender and a clinical diagnosis of depression or anxiety before medical school (CFI = 0.98, TLI = 0.97, RMSEA = 0.05; see Table 2). There was a positive and statistically significant relationship between a prior clinical diagnosis of depression or anxiety and depressive symptoms (b = 0.16, 95% confidence interval [CI]: 0.10, 0.21; P < .001); males were less likely to report depressive symptoms (b = −0.10, 95% CI: −0.16, −0.04; P < .01). After controlling for gender and clinical diagnosis of depression or anxiety before medical school, both a lack of institutional responses to seminal race events and more frequent experiences of discrimination were associated with more depressive symptoms (b = 0.12, 95% CI: 0.04, 0.20; P = .01 and b = 0.19, 95% CI: 0.11, 0.26; P < .001). Additionally, there was a positive relationship between experiences of discrimination and institutional responses to seminal race events such that students who reported more experiences of discrimination were more likely to report that their institution did not respond to seminal race events (b = 0.41, 95% CI: 0.34, 0.48; P < .001).

T2
Table 2:
Model 1: Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms in Black U.S. Medical Students (n = 727), Controlling for Gender and a Clinical Diagnosis of Depression or Anxiety Before Medical School, August 2020a

Model 2 built on model 1 by adding an interaction term between experiences of discrimination and institutional responses to seminal race events (see Table 3). The magnitude of the relationships was similar to model 1, and all the relationships remained statistically significant. The interaction term between experiences of discrimination and institutional responses to seminal race events was positive and statistically significant (b = 0.09, 95% CI: 0.02, 0.15; P = .03), indicating a synergistic effect in predicting depressive symptoms (i.e., the relationship between a lack of institutional responses to seminal race events and depressive symptoms was stronger among medical students who reported more frequent experiences of discrimination).

T3
Table 3:
Model 2: Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms in Black U.S. Medical Students (n = 727), Controlling for Gender and a Clinical Diagnosis of Depression or Anxiety Before Medical School and Adding an Interaction Term Between Experiences of Discrimination and Institutional Responses to Seminal Race Events, August 2020a

Model 3 built on model 1 by adding interaction terms between gender and experiences of discrimination and between gender and institutional responses to seminal race events (see Table 4). The direct effects from institutional responses to seminal race events and experiences of discrimination were similar to model 1. Neither interaction term was statistically significant, indicating that gender did not moderate the relationship between experiences of discrimination and depressive symptoms or between institutional responses to seminal race events and depressive symptoms.

T4
Table 4:
Model 3: Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms in Black U.S. Medical Students (n = 727), Controlling for Gender and a Clinical Diagnosis of Depression or Anxiety Before Medical School and Adding Interaction Terms Between Gender and Experiences of Discrimination and Between Gender and Institutional Responses to Seminal Race Events, August 2020a

Discussion

This study examined the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms in Black U.S. medical students. More frequent experiences of discrimination were associated with more depressive symptoms. Students who reported that their institutions did not respond to seminal race events were also more likely to report depressive symptoms. Additionally, there was a synergistic relationship between experiences of discrimination and institutional responses to seminal race events. The relationship between institutional responses to seminal race events or experiences of discrimination and depressive symptoms did not vary significantly by gender.

These results are consistent with several prior population-level studies examining the effect of discrimination on the mental health of Black individuals in the United States. 34 In their examination of the longitudinal effects of discrimination on the mental health of Black middle-aged and older adults, White and colleagues 35 reported elevated depressive symptoms among Black individuals with high or moderate general discrimination trajectories (or levels of discrimination over time). Similarly, Torres and colleagues 36 examined the effect of racial microaggressions on the mental health of Black doctoral and postdoctoral students, finding that discriminatory behavior that underestimated personal ability was associated with greater perceived stress and depressive symptoms. By describing the cumulative negative effect of discrimination (via more frequent experiences of discrimination and a lack of institutional responses to seminal race events) on Black medical student mental health, we add to the current literature and provide an opportunity for institutions to examine their culture and take actions to better support Black medical students.

This study is timely and contributes to the literature by exploring the association between institutional responses to seminal race events and depressive symptoms among Black medical students. There is a dearth of studies that have examined institutional responses to seminal race events, and we were unable to identify any existing scales that assess seminal race events. The existing literature has generally examined isolated events of police brutality among Black persons (e.g., the murder of George Floyd). The current study included 3 events that significantly altered the cultural landscape and national conversation around race: the murder of Ahmaud Arbery, the murder of George Floyd, and the racial disparities in COVID-19 deaths. 37–40 These events were all associated with structural racism, sparked antiracist uprisings, and initiated conversations on how to address structural inequities. While the current study sought to determine medical students’ perception of their institution’s response to seminal racial events, future studies should also examine institutions’ specific actions in response to these events (e.g., releasing position statements condemning police brutality, adding programming to reduce implicit biases). Furthermore, studies should assess whether medical students believe the specific actions their institutions took were sufficient responses. Based on reviews of position and public statements from medical and nursing schools in response to the killing of George Floyd, Breonna Taylor, and Ahmaud Arbery, many institutions failed to adequately address the multitude of factors that led to these events. 41 For example, most of the examined statements did not address the involvement of police or the “country’s targeted, historically engrained, and sustained oppression of Black people through White supremacy.” Additionally, as noted by Knopf and colleagues, 39 the effectiveness of position statements in response to these seminal race events “remains unclear.” The authors suggest that these statements should be accompanied by funding and institutional commitments to address structural racism. For example, the National Institutes of Health’s (NIH’s) response to these events may serve as an exemplar for other institutions; the NIH is taking an “active stance against structural racism” through their UNITE Initiative. 40 This initiative includes 5 committees tasked with addressing different objectives, including reviewing NIH policies that may hinder diversity within extramural research and increasing NIH funding to support disparities research.

There are several limitations to this study that warrant discussion. First, the study included a nonprobability sample of Black U.S. medical students, representing about 10.9% of the Black medical students enrolled in the United States for academic year 2019–2020. 42 While convenience sampling is a widely accepted method, especially for preliminary investigations because of its convenience and low cost, both the nonprobability sampling and the relatively low proportion of respondents limit the generalizability of our findings. It is important to note that our study population was similar in age and depressive symptoms to other U.S. studies of medical students. 24 Relatedly, the current study used social media and listservs as recruitment methods. The use of electronic listservs and social media for survey recruitment has grown over the past decade and has become more common given the COVID-19 pandemic. 43–46 While this strategy for recruitment allows for rapid survey dissemination, access to hard-to-reach populations, and is cost-effective, it has limitations (see McRobert and colleagues 46 for advantages and disadvantages of common survey recruitment methods). One of the major limitations is the inability to calculate response rates using social media recruitment. 26,27,46 Studies that have used this recruitment method have reported completion rate as one metric, and our conservative completion rate was 73.3%. Similarly, we were unable to determine the number of students who received and opened the email from the SNMA and OSR listservs. Based on previous studies, we can assume that our response rate was low. 43 Despite the inability to report response rate, we believe the recruitment methods used in our study (i.e., social media and listservs) were reasonable given that Black medical students are often underrepresented in research studies. 44–47 For example, the Medical Student Cognitive Habits and Growth Evaluation Study excluded medical schools at historically Black colleges and universities, 47 the populations of which account for over 10% of Black U.S. medical students. 48

Second, we included a limited number of seminal race events. As mentioned previously, there are few studies that have examined seminal race events. The low number of items included in our scale may partially explain the low Cronbach’s alpha for this scale (0.61). That is, Cronbach’s alpha is influenced by the number of items in the scale as well as the sample size. 49–52 The scale was also modeled as a latent variable and had acceptable fit indices, which supports its inclusion in this study. However, the low Cronbach’s alpha is a limitation and suggests the scale could be revised to improve internal consistency reliability. Future studies should consider including additional items that examine institutional responses to seminal race events, including positive seminal race events (e.g., the swearing in of the first minority female Vice President). Lastly, this study was cross-sectional, so we could not examine the longitudinal relationship between institutional responses to seminal race events and depressive symptoms.

Despite these limitations, our study may provide insights into how institutions could potentiate mental wellness for Black medical students. Black medical students are exposed to the normal stressors of pursuing medicine (e.g., long hours, high-stake exams, death of patients) in addition to racial discrimination from patients and colleagues (with reported rates as high as 71%) 53 and witnessing the killing of unarmed Black persons, all in the midst of a global pandemic that has disproportionally affected Black persons. The synergistic relationship between experiences of discrimination and the lack of institutional responses to seminal race events in our study is suggestive of a perceived lack of institutional support among Black medical students and represents an area of actionable improvement for medical schools. Responding to seminal race events and raced-based trauma may improve mental health and other outcomes, including academic success, among Black medical students. 47,53 For example, First and colleagues 11 describe the necessary role of support and mental health resources for community members experiencing race-related events, such as the shooting of Michael Brown and the civil unrest that followed in Ferguson, Missouri. Additionally, Gray and colleagues 38 offer a 4-pronged approach for academic medical centers to address structural racism: (1) commitment to recruiting, retaining, and promoting a diverse workforce across institutions, (2) implementation of strategies to “stop the line for racism,” (3) formation of committees that include the local community to review institutional health equity policies and provide advice on antiracism programming, and (4) critical review of existing institutional policies.

Racial discrimination is both a public health and an institutional crisis. Institutions dedicated to supporting Black medical student wellness, as well as the pipeline of future Black physicians, must be both diligent in cultivating a culture intolerant of discrimination and deft in their responses to seminal race events in the larger culture. Future studies should examine interventions and strategies implemented by institutions to mitigate the impact of discrimination on medical students’ mental health as well as its association with recruitment, retention, and the academic success of diverse populations.

Acknowledgments:

The authors wish to thank the Student National Medical Association for their help with this study.

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