Being Black in medical school comes with a different set of challenges; including a paucity of Black role models, microaggressions from patients and colleagues, and a persistent awareness that many in society have concluded that many of us are intellectually inferior to our peers.1,2 The perpetual sentiment that we must be excellent at all times, work twice as hard, and that the same naive errors deemed “expected” for majority students somehow reflects our competence.3 Many Black medical students experience the stress that comes with conforming and assimilating on the wards to gain the approval of our often White evaluators. Often, many of us are requested by patients of color to advocate for them and feel obligated to do so because of the disparities that exist. Imposter syndrome, tokenism, stereotype threat, microaggressions, and homophily are just some of the burdens and challenges we navigate on a daily basis.4 The residency interview process consolidates these challenges as Black Medical students try to demonstrate their authentic selves while being relatable and defying the stereotypes frequently associated with people who look like us. Presently, a new tribulation presents itself as the era of virtual assessment becomes our reality. Although challenging for all, new considerations for Black medical students arise.
Assessing “belonging” is one of the greatest concerns for most Black trainees looking at a residency program. Before the virtual era, one could walk the program's halls, see the patients the trainee will serve, and feel the sincerity of interactions with peers and staff. Then, it was easier to assess a program's commitment to diversity and the student's fit. Today, many Black medical students have to consider whether a program of interest will be a place where they will be subjected to constant microaggressions and struggle being their authentic selves. Black applicants are left to wonder if they are being recruited as a token, to fulfill a quota, or truly desired as an asset to a diverse program. Environments where Black students must assimilate the most increase stress about the likelihood of burnout and loss of their identity during the tasking years of residency.5 To avoid such environments, many Black medical students scrutinize the residency and faculty profile pictures online, hoping to see people who look like them. Unfortunately, this is an exercise in futility, because the reality is that Black representation, particularly that of Black men in medicine, has been dwindling over the last 40 years.6 Ultimately, many Black applicants often settle for programs that seem more relatively diverse than others. Black trainees convince themselves that this will serve as a great equalizer in determining fit and success in the training program.
Likewise, residency programs are also assessing an applicant's overall fit. This term goes deeper than an applicant's career interest and must include the integral connection of personalities amongst its residents. The concept of fit has led to what many in the underrepresented minority in medicine community label as “code-switching.” This has been described as a linguistic phenomenon that has been a part of a Black experience in the United States for centuries.7 Since its name was coined in 1954, this term is used to describe how an individual alters their speech, behavior, appearance, or expressions to pacify the comfort of another social group.8 Although not explicitly mentioned in medical communities, this phenomenon has gained traction amongst institutional and professional settings as a skill set not only necessary for success, but survival in mainstream culture.9 As the residency interviews transform to the virtual platform, many Black applicants may find it even more challenging to connect due to the relative barrier to assimilate virtually where nonverbal cues are accentuated. Virtualized events, such as the pre-interview “meet and greets,” and engagement throughout the actual interview experience, scrutinize applicants’ mannerisms, and hobbies. Although not explicitly stated, it is no secret that applicants are looked upon more favorably if they not only attend but engage in these sessions. Many Black medical students who do participate struggle with being their natural selves, constantly guessing what biases are being applied to them. The seminal moment that highlights these experiences virtually is during the pre-interview “ice-breaker” activities. This struggle is not due to the Black student's intrinsic personality, but the implications behind the prompts, “tell me about your hobbies,” and “one interesting thing about me.” Many of these sessions are intrinsically tilted towards stereotypical cultural interests of the majority and are most engaging to the students who share those interests. An applicant who does not share these experiences becomes isolated and pressured to find similar hobbies for fear of not fitting in. As an unintended consequence, these environments created may serve as a way of self-selection, where Black applicants become disinterested from programs that have not objectively reflected inclusivity within their program.
As programs rely on virtual assessments, small nuances of appearance now play an even more vital role. The impact of implicit bias of residency selection committees has already been well established. Applicants who are facially unattractive or obese are often evaluated less favorably.10 These same biases apply to Black applicants as well. Many Black men feel compelled to shave their faces completely, and many Black women groom their hair in a style that would be more appealing and conservative in an effort to appease programs that will decide to train them.
Here are our impressions amid the virtual interview experience. The Black Lives Matter’ movement has sparked a cultural awakening of America's conscience, peaking after George Floyd's death. Subsequently, many residency programs have created diversity committees to support groups from all backgrounds. It is not clear, however, if these efforts are sincere or reactionary. Their timeliness cannot answer whether these are attempts to be popular in recruitment or genuine commitments to hire more trainees and faculty of color. As a result, the onus has fallen onto the trainee to recognize and decipher these efforts’ sincerity. Sincerity could be affirmed through transparency in how success in these efforts is evaluated. Programs rarely share this information on the interview trail, and Black applicants are afraid to ask. Many of us fear that uncomfortable questions might be viewed as “controversial” and result in backlash or being negatively evaluated by the program. This is an unacceptable consequence in virtual interviews where impressions are made in the span of a 20-minute encounter. Information regarding the various departments’ efforts in diversity, equity, and inclusion (DEI) are often available online. However, these links often refer us to the larger institution's DEI mission statement and goals and rarely share how the specific department of interest is working to create an inclusive environment.
The impact of COVID-19 on residents, and how they are supported during the pandemic is frequently mentioned in interview sessions. Issues of social justice and events surrounding the deaths of unarmed Black people this summer are rarely mentioned. Programs seem less comfortable speaking on these topics, and this inevitably leads to the perception that these issues are not impactful to resident wellness.
As we prepare for ranking, many of us acknowledge that the inability to assess fit has driven us to give stronger consideration to programs that are in areas with larger minority populations. We question if we can find belonging in less diverse areas or areas with a culturally insensitive history. We recognize that programs with less diversity come with the added burden of proving we were desired for our merit and not ethnicity.
Virtual assessments of medical trainees may be the norm for a while. We believe that programs’ understanding of the concerns and considerations of Black medical students is the start to recruiting more diverse medical professionals. Assessing belonging and sincerity is difficult in person; it is more so virtually. Assimilating, as a Black medical student, to prove fit to a program comes with a great deal of stress as well. Programs will have to continue to work hard to describe and demonstrate their culture to all applicants. As the formation of DEI committees becomes more popular, tangible goals for recruitment should be created and shared widely. This can be accomplished with addition of this information to the residency websites, and specific mention of these goals in presentations during interviews. We commend and encourage meet and greets specifically for underrepresented minorities in medicine as this affirms to us the program's commitment to recruiting a diverse residency class. Programs who share their values for creating a diverse and inclusive environment through statements on their website also reaffirm to us that they are responsive to the concerns of minority trainees. Frequent communication occurs amongst applicants and residents along the interview trail. With the inclusion of minority residents on DEI committees and recruitment of diverse faculty and applicants, programs will gain positive reputations for creating an environment where everyone feels they belong.
The authors would like to acknowledge Ashley Meagher, MD MPH for inspiring and reviewing this manuscript, and Brian Brewer, MD MBA, Clark Simons MD, and Aaron Carroll MD MPH for their critical review and revisions.
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