Medical students who report being mistreated or discriminated against are far more likely to drop out of medical school, according to a study published Tuesday in JAMA Pediatrics.
Previous studies have linked discriminatory treatment in medical school to burnout and depression among students. The new paper is the first to link discrimination to medical school attrition, according to the authors, and it may be one reason the number of students from many racial and ethnic groups underrepresented in medicine has declined in recent decades despite efforts to diversify medical school classes and the profession in general.
The study included nearly 20,000 students who started medical school in 2014 and 2015 and who completed a survey administered to second-year medical students by the Association of American Medical Colleges (AAMC). They were asked about instances of mistreatment and discrimination by faculty, staff, and other students, including being publicly humiliated, physically harmed or threatened, or denied opportunities; receiving lower grades or evaluations; or experiencing offensive remarks based on race, ethnicity, or gender.
The study compared these reports to attrition rates of the students and found that those who reported no mistreatment had attrition rates of 1.2%, while students who reported recurrent (two or more experiences) of mistreatment had attrition rates of 4.1%. Students reporting recurrent experiences of discrimination had attrition rates of 1.9% compared to 1.3% for students reporting no discrimination.
Mistreatment and discrimination led to higher attrition rates for all sexes, races, and ethnicities, except for Asian students, whose attrition rates were among the lowest. The study found the highest attrition rates in students from underrepresented groups who reported mistreatment or discriminatory behavior.
The authors said their study likely underestimated the true attrition rates for students of color because those students had been less likely to fill out the AAMC survey and were also more likely to have left medical school before completing two years. (In the study, underrepresented groups included students who were Black, Hispanic, Native American, Alaska Native, Hawaiian, and Pacific Islander.)
“The finding wasn’t surprising to me, honestly, based on what I’ve seen and heard,” said the study’s lead author, Mytien Nguyen, a Vietnamese and Black M.D.-Ph.D. student at the Yale School of Medicine who is a first-generation American and from a low-income family. Nguyen said she was motivated to conduct the study to determine why she saw so many students of color in her cohort leaving medical school or taking leaves of absence. Mistreatment and discrimination, she said, “just compounds the issue when you are already asking ‘Is medicine right for me?’”
Many leaders in medicine are seeking to make the profession more representative of the nation’s demographics, in part because studies show that people seen by physicians that look like them often have better health outcomes. This new study suggests focusing on diversifying medical school enrollment may be far too limited of an approach to tackling the continuing lack of diversity within medicine.
“We think there’s been a focus on recruiting diverse individuals and less attention to the learning environment,” said Dowin Boatright, a Black assistant professor of emergency medicine at Yale and senior author of the study. Boatright said medical schools needed much better, and quicker, systems to collect data about mistreatment and discrimination from students and deliver that data to medical school faculty so they can learn from it and improve their behavior.
“We’re not trying to cancel people,” he said. “It’s like quality improvement measures in a hospital. When there’s a mistake, we want to better understand what happened so people can grow.”
A study Boatright co-authored and published last year found that a majority of medical students from marginalized groups reported experiencing microagressions at least once a week and that these incidents were associated with both depression and thoughts of leaving medical school.
Rather than blaming the dearth of medical students of color on social problems like early childhood education or poverty, Boatright said medical schools needed to be remedying what they can to keep their students supported, enrolled, and successful. “By looking downstream,” he said, “the institution of medicine can put blame elsewhere without having to fix the problems in its own house.”
Geoffrey Young, who directs an initiative to transform the health care workforce at the AAMC, said his organization was working with medical schools across the country to make learning environments not only diverse, but also inclusive and equitable for all students.
“We not only have to address the limited pathways for those that have been historically excluded from medicine,” he said, “But we also have to address, when they arrive at our doors, what are the issues that may keep them from thriving?”
He said medical schools have to work to better understand the experiences and struggles of students who have been historically excluded, to support such students “from day one,” and to make sure all students have a means to safely report mistreatment and discrimination to school leadership.
“If we help our most vulnerable students to thrive,” Young said, “we expect all students will thrive.”
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