What will it take to level the playing field for Black residents?

This is part two of a STAT investigation on the dismissal of Black doctors from residency programs. For part one, click here. 

Black doctors are terminated from or leave their training programs in far higher numbers than white physicians, a problem that STAT reported this week has long been hidden and ignored by the medical establishment and contributes to the chronic lack of Black physicians, especially in the most elite fields of medicine.

While the causes are complex and sometimes hard to nail down — and structural racism is embedded in medicine as in the rest of U.S. society — scholars and physicians working to address the issue say there are straightforward steps that residency programs and oversight bodies can take to make a difference.

Solutions they advocate include collecting and making public data on a problem that has been largely invisible; improving due process protections for residents who feel they’ve faced discrimination; providing mentorship and coaching for Black residents; and increasing oversight of residency programs.

“We have to stop letting this happen,” said Vanessa Grubbs, a Black physician and author in Oakland, Calif., who recently co-founded a group called Black Doc Village to help residents facing discrimination. “They’re picking us off one by one.”

Collect the data

Many say the first step in addressing the attrition crisis for Black residents is measuring how big the problem is. Data on the race and ethnicity of residents forced out of programs have not been routinely tracked or published by the programs or specialty medical organizations, leaving individual physicians scrambling to bring attention to the issue.

Edjah Nduom, a Black associate professor in the department of neurosurgery at the Emory University School of Medicine and co-founder of the American Society of Black Neurosurgeons, combs social media and uses other methods to track the fate of Black residents in his field. “It’s annoying because the data exists,” Nduom said.

A similar focus on numbers in recent decades has helped address the challenges faced by women and markedly increased their numbers in fields like neurosurgery and urology, he said, adding that the same attention should be given to trainees in racial and ethnic groups that are underrepresented in medicine.

Nduom’s group is calling for dissemination of national data on residency termination by race and an accounting of residents who are dismissed or withdraw from individual programs so medical students can avoid programs with a poor history of graduating Black residents — and so these programs can be held accountable.

Owoicho Adogwa, a Black assistant professor of clinical neurosurgery at the University of Cincinnati and a co-founder of the Black neurosurgery group, tells mentees which programs to avoid: those that have yet to graduate a Black trainee, and those with a history of firing Black trainees. While he doesn’t feel it is his place to publicly out these programs, he thinks a group like the Accreditation Council for Graduate Medical Education, or ACGME, which accredits residency programs, should require a public accounting of failure rates by race of all residency programs. “We are doing a disservice by not publishing these numbers,” he said.

He points to what happened after the NCAA started holding colleges accountable for graduation rates of student athletes. Similar transparency by residency programs, Adogwa thinks, will accelerate efforts to support and graduate their Black residents so they don’t look bad compared with their peers. “No one wants to be at the bottom of the pile,” he said.

The number and race or ethnicity of residents put on probation is another metric that should be reported, said Dowin Boatright, an assistant professor of emergency medicine at Yale who has studied the impact of race on residency training. “We’ve heard anecdotally that many residents of color are put on probation without due process, then that stays on their record when they go to look for a job.”

Such demerits, he said, may be one reason Black physicians aren’t progressing as far in their careers after residency, and remain scarce in academic faculty positions. “Can you become a chair of a department if you have to disclose you’ve been put on probation?” he asked.

Until such numbers become publicly available, some say there is need for a Green Book to guide Black residents to programs where they will feel safe and be treated fairly, similar to the Negro Traveler’s Green Book, which from 1936 to 1967 steered Black travelers to safe hotels and restaurants. Ironically, the American Medical Association’s longtime official directory of graduate medical programs — due to its green cover — was called the Green Book.

Improve protections for residents

A number of studies show implicit bias can lead to lower rankings of medical students and residents. In many residency programs, because there are few checks and balances against the power of program directors, those who draw the ire of leadership have little recourse. “If the people leading these programs are not wanting you to succeed,” Adogwa said, “you are not going to succeed.”

Many Black residents told STAT that the appeals processes their programs offered were laughable, and they felt they had nowhere to turn for real help. “People get sent to the diversity and inclusion officer, or HR, but all of these folks are there to protect the institution,” said Grubbs. “They leave these young people by themselves and don’t give them any support. They can’t even bring faculty into the room with them.”

Grubbs’ group plans to stage a demonstration in August to raise awareness about the unjust dismissals of Black doctors and trainees. What’s needed, she said, are firm due process guidelines, and sanctions from ACGME or even the Centers for Medicaid & Medicare Services, which funds residency programs and used the cudgel of withholding funding to desegregate hospitals in the 1960s.

At the very least, she said, residents should be allowed to have a faculty member or faculty member in the room with them during disciplinary proceedings. “It’s so unfair for a resident to be fighting this by themselves,” she said.

Residency training programs are accredited by the ACGME, though the nuclear option of removing a program’s accreditation is rarely used.

The ACGME has an office of the ombudsman that residents can contact with complaints. But a number of residents interviewed for STAT’s investigation said they had received little help from the ACGME when they contacted the office about problems related to racial discrimination. “They have largely abdicated their responsibility to protect residents from underrepresented groups,” Adogwa said.

Other residents told STAT they were reluctant to contact the group at all because it is led by former medical school and residency programs leaders with close ties to current program directors. “Am I supposed to have confidence in these people?” asked one resident who was terminated from a residency and asked to remain anonymous because of fear that speaking out could impact their new career. “I’m just a resident, but program directors — those are their friends,” said another. “At the end of the day, people in power protect each other.”

The ACGME is funded by the programs it covers. “There are a lot of conflicts,” said Grubbs. “ACGME is paid by programs to do accreditation. They’re not paid if a program is not accredited. Does that interfere?”

ACGME leaders, through a spokeswoman, declined a request to be interviewed for this story and said that the group does not adjudicate disputes having to do with discrimination or dismissal. Others say the organization was a decade behind others, such as the American Association of Medical Colleges, in hiring diversity officers. Many credit the work of the ACGME’s recently hired chief diversity and inclusion officer, anesthesiologist William A. McDade, with furthering efforts to diversify the physician workforce; it was his analysis that showed residents of color were being terminated or withdrawing at high rates. The group is preparing a more detailed analysis of withdrawal and termination rates from more recent years, a spokeswoman for the group said.

Work to support, not ‘weed out’ residents

Some residency programs are doing a better job supporting their Black residents, including several at the Mayo Clinic. It’s almost unheard of for a resident to not finish the Mayo’s extremely competitive neurosurgery residency program, said its director, David Daniels. It’s even rare, he said, for a resident to require an individual learning plan, something the program offers residents needing additional help.

The program’s success partly stems from the Mayo’s one-on-one mentoring program — something that’s been in place in many of the institution’s surgical residency programs since the Mayo brothers practiced and taught surgery in the late 1800s. “I work with one person for three months and get to know that person really well,” said Daniels. “You build a relationship and you care about them.”

The program is also diverse. The newest class of four neurosurgery residents, he said, includes two Black men, a South Asian woman, and a white woman. Daniels said that diversity has been a longtime focus of the program and of leadership at Mayo, which for years has invited students from historically Black medical colleges without neurosurgery programs to train during summers. Many later apply to be residents.

There’s similar support in the Mayo’s otolaryngology residency program. Director Janalee Stokken said she’s working to bring in more residents from underrepresented groups and make sure they feel supported, including by relying less on test scores to screen applicants, bringing in speakers from diverse groups, and offering residents the chance to work with underserved populations in both Rochester, Minn., and Zimbabwe.

In Stokken’s program, new residents get preassigned mentors so they have someone to go to with questions. They have access to groups on campus for students from different ethnic and racial groups, or with different sexual orientations. But perhaps most importantly, the culture in the program is that everyone should succeed.

“If you make it as far as to match into an ENT program, you probably should be able to finish,” Stokken said. “It is not my goal to weed anyone out.”

Her approach, when she sees a resident in trouble, is the very opposite of the isolating silence that many Black residents said they’ve experienced elsewhere. “When I see a resident struggling, I start meeting with them more. I want to figure out how I can help,” she said. “I try to be an advocate. Everyone has my cell phone.”

For Stokken, such work is personal. She is white but also struggled in her residency in otolaryngology, a field that has not always been open to women. “Frankly, I’ve lived that story. You don’t fit in and it eats at you and makes it harder,” she said. “But you can struggle in residency and still become a program director at the Mayo Clinic.”

Don’t wait to ask for help

Black physicians who survived residency have plenty of advice for those who are following them. It’s important, said Nduom, for residents to be aware of any disciplinary actions taken against them and take action before it’s too late. “They need to know this is the first pattern to look for,” he said. “They need to recognize the first sign of smoke.”

They also need to question faculty who, when they ask residents to sign off on disciplinary paperwork for things such as probation, say probation is no big deal and won’t stay on their permanent record. “Any academic blip — taking time off, academic probation, or needing extra time — is reportable for any future hospitals, state, or DEA licenses regardless of what the program director or chair says. It will follow you,” said Letitia Bradford, an orthopedic surgeon who serves as executive director of Nth Dimensions, a group seeking to increase diversity in orthopedics.

Bradford also advises residents to take their licensing exams as soon as possible, even during the first year. That way, if they are dismissed from a specialty program, they can still practice medicine somewhere, perhaps working at an urgent care clinic, for example.

Nduom and others said residents being disciplined should immediately seek help from a trusted mentor in medicine and be wary when leaders of the program that wants to dismiss them tell them they’ll easily find a spot in a new program. “They say that, and at the same time, they’re on the phone with other program directors telling them ‘This person should not be a neurosurgeon,’” he said.

Shenelle Wilson, an Atlanta pelvic reconstructive surgeon who has set up a program to mentor aspiring urologists, said residents should document everything that happens to them, from achievements and praise they receive, to racist behavior they encounter. “I was raised by a lawyer who made me write down everything,” she said, adding that she used the material to contest claims being made against her, such as not covering shifts for other residents. “I had the receipts. They can be vague in their feedback and criticism, but you have to have 1,000 examples to counter what they say.”

Wilson also advised residents to send regular emails to supervisors asking for feedback and asking specifically if there is anything the resident should address. “If they don’t say anything back, that’s tacit agreement they see nothing wrong,” she said. “Then you’re building your case. You have to craft your story.”

And be sure all of that documentation is going to an outside email, Bradford warned, because one of the first things terminated residents lose is access to their institutional email.

Relationship building is also key to success in residency, physicians said. It’s important to make friends and build connections with fellow residents and faculty even if they come from vastly different backgrounds. “In the ideal world, you endear yourself to people,” Nduom said. “You let them get to know your story.”

What the future holds

There has been a lot of change in both medicine itself and in residency programs since 2020, when awareness about structural racism in medicine skyrocketed due to both the Covid pandemic and the racial reckoning brought on by the death of George Floyd. Change is palpable: The number of Black trainees that are applying and being selected for spots in elite specialties such as orthopedics and thoracic surgery is on the rise.

But there is also growing concern that Black residents are being aggressively recruited by programs — almost like college athletes, one program director said — to signal that efforts are being made to promote diversity, but that those same residents may not be well-supported once they arrive at their new programs. “We think there’s been a lot of focus on recruiting diverse individuals and less attention to improving the learning environment,” said Boatright, from Yale.

Unlike other elite fields, neurosurgery has not had a shortage of Black applicants, possibly due to “the Carson effect” — Ben Carson’s 1990 book “Gifted Hands,” which inspired generations of young Black children to consider neurosurgery as a possible profession.

But as the number of trainees in the field rises, some worry that they could see a zero-sum game, with the number of Black trainees dismissed each year rising as well.

In recent years, about 8 students have matched into the nation’s roughly 234 neurosurgery residency spots each season. This year, Nduom, who tracked the numbers on Match Day via the many joyous announcements made on Twitter, said a record high 25 Black candidates had matched. In orthopedic surgery, 53 Black students matched this year. These young doctors are about to start their journey toward becoming specialty physicians.

The question is: Will they be allowed to finish?

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.