BACKGROUND

In response to the COVID-19 pandemic and the 2020 nationwide uprising supporting Black lives, the Association of American Medical Colleges (AAMC) released a framework for addressing and eliminating racism at the AAMC, in academic medicine and beyond.1 The first step of the AAMC’s framework is to “begin self-reflection and educating ourselves.” Indeed, historical and contemporary patterns of racial exclusion fundamentally shape medical schools, and current institutional structures often serve to entrench rather than dismantle racial inequality for students, faculty, and patients. Decades of evidence demonstrating a lack of improvement in workforce diversity and disparities in trainee and faculty experiences suggest as much.

This narrative review synthesizes scholarship on race and racism in medical training to demonstrate that medical schools are racialized organizations with longstanding institutionalized structures that prioritize the dominant racial group and negatively impact the careers of non-White individuals, particularly those underrepresented in medicine (URIM). For this review, we define URIM as those who identify as Black, Hispanic, and Indigenous. We apply the sociological theory of racialized organizations to show how racial structures within medical schools impact trainees’ educational and health outcomes and have implications for organizational health, patient care, and society at large. We conclude with a call to action for medical schools and organizations such as the AAMC to use existing evidence to create structural solutions for structural problems.

THEORY OF RACIALIZED ORGANIZATIONS

The theory of racialized organizations2 posits that formal and informal organizational processes privilege certain racial groups at the expense of others, as “the meanings encoded in the concept of race provide a template for organizational action.” Organizations distribute resources in ways that constrain (or enable) the expression of individual agency or the ability to shape one’s future. Resources include tangibles like financial assets and less tangible factors like mentorship and professional development opportunities. The theory argues that Whiteness functions as a credential, providing greater access to leadership or the benefit of uneven application of formal rules and policies.

Certainly, whether non-White individuals are considered “racially palatable or not overly concerned with race” shapes if and how they are hired, promoted, and accepted within organizations.3 Many procedures considered race-neutral—like expectations of code-switching (which draws on White norms) or “aptitude tests” (which partially measure racialized patterns of access to resources)—reinforce the relegation of some non-White people to an inferior status. In other words, seemingly race-neutral rules, processes, and structures in conjunction with individual biases and discrimination may limit or enhance individuals’ potential and achievements along racial lines.

A readily observable way that organizations shape resource distribution and agency is through segregation. Historical segregation was designed to concentrate resources. Within present-day organizations, non-White people are typically relegated to less remunerative jobs, with little authority.5 These processes of organizational segregation create a path-dependency that helps justify contemporary patterns of racial inequality within medical schools as “just the way things are.” For instance, the Flexner report, whose recommendations led to the closure of all but two historically Black medical schools,6 continues to have ripple effects limiting Black agency. A recent study showed historically Black medical schools would have trained approximately 30,000 additional Black physicians,7 which is particularly important, as Black physicians are more likely to work in Black and underserved communities.8 Scholars have applied the theory of racialized organizations to various organizational settings, including education and business.9,10 Below, we expand on a recent introduction of the theory and its application to medical schools.11

MEDICAL SCHOOL ADMISSION

While formally race-neutral measures are used to grant admission to medical school, longstanding patterns of racial exclusion impact students’ performance. Thus, the Medical College Admission Test (MCAT), college grades, and extracurricular activities such as clinical shadowing carry the residue of historical and contemporary patterns of racial discrimination. Studies show URIM applicants have lower MCAT scores than non-URIM applicants.12 Rather than solely being a marker for intelligence and ability to handle rigorous medical training, the MCAT partially reflects access to resources and thus unwittingly serves as a barrier to entry for some URIM students.13

Structural racism’s impact on non-Whites’ economic standing also influences the admissions process. URIM applicants are disproportionately from low-income households and overrepresented in the lowest strata of the AAMC’s parental education and occupational indicator, compared to non-URIM applicants.14 Socioeconomic status is a strong predictor of MCAT performance.15 Applicants with midrange MCAT scores are often overlooked, despite evidence that they succeed in medical school when admitted, and schools that accept more applicants with midrange scores have more diverse matriculating classes.16 Additionally, URIM applicants report lacking shadowing and extracurricular educational opportunities valued in the admissions process.17 The overreliance on test scores and mainstream extracurriculars are institutionalized mechanisms of racial exclusion shaping URIM applicants’ agency by curtailing their career options. Furthermore, URIM applicants report experiencing racial bias during medical school interviews.18

MEDICAL STUDENT EXPERIENCES AND EDUCATIONAL OUTCOMES

Discriminatory processes of racial sorting do not end upon medical school admission. During medical school, racialized processes that impact careers can be classified into broad overlapping categories, including learning climate and culture, preclinical experiences, clinical experiences, career opportunities, and the residency application process. Empirical research on the path through medical school shows a gap between public commitments to diversity and non-discrimination and the racialized reality of medical training. Ultimately, these racial structures affect students’ career prospects and trajectories, including experiencing discrimination,19,20 a sometimes hostile learning climate, and having lower odds of success in various outcomes such as grades, matching into residency, career advancement, and trainees’ health and well-being.

Learning Climate and Culture

Over one-fifth of medical students, the vast majority being non-URIM, have a physician parent or grandparent; scholars describe these students as the “doctor dynasty.” 21,22 These family experiences and connections give non-URIM students advantages in their ability to navigate medical school and greater familiarity with the hidden curriculum, including, but not limited to, signals in the learning environment that shape students’ experiences such as the allocation of resources, as well as social and cultural capital inherent to the doctor dynasty. This difference in capital materializes as early familiarity with medical jargon and access to networks of potential mentors.23 The result is that White students, in particular, benefit from a more pronounced sense of belonging, which serves as a buffer against stress and anxiety. On the other hand, URIM students report a sometimes hostile learning environment characterized by racial stereotyping and discrimination, low social support, lack of understanding from peers, feeling stigmatized as “out of place,” and a low sense of belonging.19,20,24,25 In a nationwide sample of medical students (n=3756), 64% of participants reported a hostile racial climate. Additionally, 81% and 94% respectively reported witnessing discrimination towards students and negative role-modeling, such as physicians speaking negatively about Black patients.26

Socioeconomic status may partially explain such experiences. Many URIM students contribute financially to their families, despite their reliance on student loans.20 This is especially true for Black students, who carry a significantly greater debt burden at matriculation due to the racial wealth gap.14 Furthermore, people tend to associate Blackness with lower status occupations, 27 which likely exacerbates the existing class-based divide and informs the aforementioned negative attitudes and hostile behaviors towards Black students. Additionally, professionalism, an important factor in evaluations, is often codified in classist, Eurocentric standards of appearance and behavior and has historically been used to police, reprimand, and penalize students outside of this mold.28 An example is discrimination against Black hairstyles,29 so common in broader society that the CROWN (Create a Respectful and Open World for Nature Hair) act has been introduced in state and federal legislatures to forbid natural hair discrimination.30

Preclinical Years

Formally neutral evaluation processes are often discriminatory in practice, with non-White, especially URIM students judged more harshly. On paper, the expectations for all students are the same; in reality, students of color face an additional set of race-based expectations. During the preclinical phase of medical school, URIM students feel that faculty and colleagues devalue their contributions. However, faculty often conscripts URIM students into educating their colleagues specifically about racial inequality and health disparities.31 This unwanted role of “racial ambassador” shifts the responsibility for educating students from faculty to students while also taking away from URIM students’ learning experiences. Similarly, URIM students report facing expectations to fulfill additional responsibilities such as serving on leadership committees and helping other URIM students navigate training, a phenomenon known as the minority tax.19,20 While leadership opportunities can enhance career opportunities; when excessive, they have the potential of becoming hindrances to academic success.

Social interactions are also shaped by race, as URIM students report that their colleagues scrutinize their same-race friendships and gatherings yet demonstrate a lack of appreciation for diversity, undermining the potential of intergroup relationships.20 A social and learning environment where many URIM students feel unwelcome and unsupported may activate stereotype threat. Stereotype thread occurs when “cues in the environment make negative stereotypes associated with an individual’s group status salient, triggering physiological and psychological processes—including anxiety, negative cognitions, and emotions, decreased working memory capacity—that have detrimental consequences on student performance.”32 Indeed, some URIM students report a lack of confidence and self-doubt which they feel is exacerbated by experiences of tokenization and the pressure of being one of few members of their racial/ethnic group.20

A hostile racial climate may impact some students’ testing experiences: Black students are at greater risk of lower self-confidence in their cognitive abilities than White students.33 High stereotype threat environments are associated with testing anxiety and worse performance, including US Medical Licensing Exams (USMLE).34,35,36 URIM students on average have lower USMLE scores than their non-URIM counterparts.37 Of note, greater premedical debt is associated with worse USMLE performance.38,39 These contextually conditioned outcomes are often interpreted as individual failings, laundering structural discrimination by blaming those affected. In contrast, the racialized organizations perspective locates the source of measured racial differences in entrenched biases built into facially neutral processes.

Clerkship Years

The unacknowledged credential of Whiteness also shapes clinical rotations. Students of color perceive that their White colleagues receive better treatment, and are better incorporated into the social aspects of the workplace, likely translating to more invited involvement in clinical care.20 Discrimination and lack of inclusivity from physicians, staff, and patients40 likely contribute to stereotype threat. A recent study showed that Black clerkship students had the highest rate of stereotype threat (82%), followed by Asian (45%) and Hispanic students (43%) compared to a minority of white students (4%).41 Such experiences yield clerkship grading disparities; URIM students are less likely to receive honors, regardless of other characteristics related to academic performance.42

The subjectivity of evaluations, influenced by social interactions with clinical supervisors and susceptible to racial biases, contribute to grading disparities. For instance, regarding measures deemed objective, Black students are more likely to be described with grindstone-like adjectives such as “competent,” whereas White students are more likely to be described with superlatives such as “excellent” and “outstanding.”43 Beyond comments from clinical supervisors, clerkship directors’ summaries contribute to disparities in the distribution of honors. In a single-school study, on average, compared with non-URIM students, URIM students received slightly lower clerkship director ratings (one-tenth of a point on the clerkship assessment scale) and, subsequently, half as many honors grades across all clerkships. This cumulative unequal impact is called the amplification cascade, where slight initial differences compound across domains, creating significant racial differences in long-term outcomes.44

Residency Application Process

As we demonstrate above, URIM applicants are systemically disadvantaged from the beginning. It is no surprise then that they receive fewer residency interview invitations.45 Grades, USMLEs, research publications, and honor society membership are impacted by institutionalized racial disadvantage, shaping how students fare during the residency application process. Because of an overreliance on numeric and categorical metrics like USMLEs and AOA membership, programs tend to extend interview invitations to a minority of high-achieving applicants. For instance, 12% of internal medicine applicants receive 50% of interview invitations.46 And yet, score cutoffs systematically reduce many URIM applicants’ chances of even being considered.45,47

Such processes affect the odds of matching into residency. A 10-year audit of graduate medical education placements showed lower 4-year matching odds for Asian (0.85, 95% CI 0.78–0.92) Hispanic (0.88, 95% CI 0.78–0.99), Black (0.63, 95% CI 0.57–0.70), and Native American students (0.60, 95% CI 0.43–0.84) compared to White students, adjusting for sex and step 1 score. However, these matching odds even out at the 6-year mark.48 In other words, students of color are more likely to go through the match multiple times before matriculating into residency. Still, evidence suggests that USMLE Step 1 scores are not the best predictor of performance during residency, despite being the most critical selection criteria.49,50,51

Certainly, board scores are predictive of first-time specialty board passing odds, but only at a threshold beyond which the difference between applicants in terms of success odds is negligible,52,53,54 yet beyond using cutoffs to grant interviews, program directors cite board scores as a leading factor when ranking applicants.55 This raises the need to deemphasize board scores above the threshold and support trainees who may have lower success odds at specialty board examinations. Some argue that the forthcoming shift from numerical scoring to pass/fail for USMLE step 1 will level the playing field, but it remains to be seen;56 other measures like the more clinically relevant USMLE step 2 may replace step 1 in importance, as suggested by a recent study of orthopedic surgery program directors.57

Access to Opportunity

Career advancement opportunities beyond grades and standardized test performance include extracurricular such as research experiences and membership in honor societies, such as the prestigious Alpha Omega Alpha (AOA), the medical honor society. Having research experience, publications, and membership in AOA are important criteria in the residency application process.47 But, these metrics themselves are racially skewed. Access to mentors is a crucial component to succeeding in research, but a multi-year study of students’ theses at a prestigious medical school showed effective mentorship was strongly associated with students receiving the highest honors; and adjusting for gender and academic performance, URIM students still had the lowest odds of being awarded highest honors.58 Similarly, A large national study showed Black and Asian applicants were respectively six and two times less likely to be AOA members compared to White applicants regardless of objective characteristics otherwise associated with membership such as clerkship grades and USMLE scores.59

IMPACT ON CAREER TRAJECTORY AND MENTAL HEALTH

Effects on Career Trajectory

The abovementioned processes steer URIM students into less remunerative specialties, congruent with stereotypes about intelligence, capability, and monetary worth. In addition to lower odds of matching by year four, URIM trainees’ careers are affected in terms of specialty (and thus earning potential), and advancement in academia. URIM students enter medical school expressing more interest in serving underserved communities;8 but this interest is often conflated with an interest in primary care. Many trainees report feeling a particular lack of mentorship and belonging when interested in surgical specialties.60 Black and Native physicians are more likely to practice primary care compared to their colleagues.61 While students’ interests change for multiple reasons, these factors are often influenced by racialized experiences.

Racialized occupational sorting limits the number of potential mentors available to URIM students, impacting students’ trajectories. A longitudinal study showed that role model exposure significantly increased students’ odds of going into the role model’s specialty, especially for lifestyle-friendly specialties.62 However, these more lucrative specialties are the least racially diverse,61 and lack of faculty diversity renders it challenging to identify mentors invested in URIM students’ success. A study of orthopedic surgery showed that URIM representation among faculty and residents was associated with a greater likelihood that URIM medical students at that institution would apply in orthopedic surgery.63 Furthermore, the more lucrative specialties (e.g., dermatology, ophthalmology) tend to place a higher value on USMLEs when evaluating applicants.64 And while the growing debt burden is often cited as a driver of students choosing more lucrative specialties, this has been empirically challenged; in fact, students going into primary care are most indebted by graduation, while those choosing lucrative specialties have the least debt.65

Even when they choose lucrative specialties, URIM students remain disadvantaged by the selection process. A study of orthopedic surgery applicants showed that matriculation rates were consistently highest for White applicants over 10 years, followed by Asian, then Hispanic applicants, and lowest for Black applicants.66 The authors highlight that while Black applicants had more volunteering experiences, White and Asian applicants had higher USMLE scores and were more likely to be in AOA. They posit that URIM applicants are competitive for orthopedic surgery from a holistic perspective but discounted in part due to the overreliance on USMLEs and AOA membership.

During residency, residents of color experience a hostile learning environment and pressures to serve as racial ambassadors.67 For example, a national study showed that racial discrimination was highly prevalent among surgery residencies, and residents who reported discrimination were more likely to experience burnout and thoughts of attrition.68 Black faculty report workplace discrimination and barriers to career advancement,69,70 and are twice as likely to consider leaving academia,71 half as likely to be promoted at each rank,72 and half as likely to be granted federal research awards compared to White faculty.73 Even after adjusting for “prior achievements,” topic choice accounts for more than 20% of disparities in NIH funding between Black and White scientists due to low award rates for research at the community and population level.74 It is no surprise then, that while underrepresented in medicine, Black physicians are even further underrepresented in academia, making only 3.6% of faculty, compared to 5.8% of physicians overall.

The racialized nature of medical schools also has implications for the career trajectories and inclinations of White students. Studies show that White students who attend school with greater racial diversity are more likely to rate themselves as highly prepared to care for minority populations and value equitable access to care more strongly.8 There is also a positive association between medical schools’ positive racial climate and gains in students’ intentions to practice in underserved areas and work with minority patients at graduation compared to matriculation.75 Such positive effects of a racially diverse environment are evident in the long run, with studies showing that through multiple pathways, a diverse physician workforce would significantly contribute to addressing racial healthcare disparities.76

Impact on Mental Health

The racialized experiences of medical training not only affect trainees’ careers, but also their mental health. Black medical students, especially Black men (who are further underrepresented, accounting for approximately a third of all Black medical school graduates, a gender gap unique to this group77) have higher levels of depression and anxiety and report low social support and harmful coping mechanisms.33 Additionally, Black medical students with greater racial identity centrality have increased odds of depression, specifically in association with experiences of discrimination.78,79 A recent, nationwide study focused on minority medical students found that microaggressions are ubiquitous, and increased frequency of experiencing microaggressions was associated with higher odds of reporting depressive symptoms.80 A previous nationwide and diverse study of medical students had shown that a hostile racial climate, witnessed discrimination, and negative role modeling in medical school were associated with worsened depression over time for all medical students, regardless of race, even after adjusting for students’ personal experiences of mistreatment.26

This mental health impact extends into residency, as residents, too, report racialized burdens and racial discrimination. A study showed that Black, Asian, and Hispanic surgery residents were 21, 6, and 2 times more likely to report discrimination than their White counterparts. Those residents who experienced racial discrimination were twice more likely to report suicidality.81 On the other hand, racial diversity within residency programs may be protective against mental illness. A study of interns from 38 institutions across 10 specialties (n=1138) found that a higher proportion of URIM interns was protective against depression among participants across racial groups, with a more significant effect on URIM interns.82

Beyond Medical Training

The racialized nature of medical schools also has consequences for organizational diversity efforts. Medical students who report experiencing microaggressions more often also report lesser satisfaction with their medical schools are less likely to recommend their school to friends, and express interest in giving back as alumni.80 In other words, the racialized nature of medical education likely unwittingly harms schools’ diversity efforts. Given the evidence that greater medical school diversity has a positive impact not only on minority trainees’ experiences and outcomes but also on those of White trainees and their career trajectories in terms of serving underserved communities, the racialization of medical schools likely hampers the often-stated goal of contributing to achieving health equity.

CONCLUSION

As racialized organizations, medical schools stunt the careers of physicians of color and uphold the status-quo in racial representation among physicians through facially “race-neutral” but ultimately biased processes. Still, medical schools and associated governing bodies of medical education, including the AAMC, can address these racialized barriers by shifting how they distribute resources to students, as evidenced by various successful examples. As has been recommended by others,83 it is paramount that these organizations leverage existing evidence to expand access to medical education, foster safe learning environments and allocate resources that will adequately, and equitably train the next generation of physicians to help address longstanding health inequities.