On day 1 of her fellowship, Francesca C. Duncan, MD, was blindsided by her first patient.
Dr Francesca Duncan
The patient, a White man who was accompanied by his wife, sat in the exam room with his sunglasses on.
“I remember him saying, ‘I need to take off my sunglasses so you don’t look so Black,’ ” said Duncan, a pulmonologist and intensivist at Indiana University, Indianapolis, Indiana, who has a specialty in lung cancer disparities.
The patient proceeded to grill her about her experience and training. He asked where she attended college and mocked her degree from a historically Black university. His wife sat there, silent.
Duncan was shocked by the fact that she still had to defend her credentials.
“I just kind of felt like at that point in my training, my title would have earned me more respect,” said Duncan, now an assistant professor after recently completing a 3-year fellowship in pulmonary and critical care medicine. “I thought at some point [the racism and discrimination] would stop, but after all that training, all that late-night studying, I still had to prove myself.”
Unfortunately, Duncan’s experience in fellowship is not unique.
A recent survey of hematology and oncology fellows revealed that medical trainees routinely encounter discrimination during their training.
The 17 fellows who were anonymously interviewed in the survey all recalled experiencing or witnessing discriminatory behaviors during their fellowship, mostly from patients. These encounters rarely come to light. Only one respondent officially reported an incident.
Dr Rahma Warsame
The findings, published online November 8 in JAMA Network Open, underscore the need for graduate medical education programs to improve learning environments and support for trainees, lead author Rahma M. Warsame, MD, and colleagues say.
Discrimination at Work
Initially, Warsame and co–principal investigator Katharine Price, MD, were tasked with developing strategies to mitigate instances of racism and bias that fellows encountered during training, but both felt it was critical to understand the experiences of their trainees first.
Out of 34 fellows and recent graduates of the hematology and oncology fellowship program of the Mayo Clinic, Rochester, Minnesota, 20 consented to participate in the study. Of those, 17 were interviewed between July and November 2018. Among the 17 interviewees, six were Asian, two were Black, three were Hispanic, two were multiracial, and four were White.
Warsame and colleagues found that everyone reported experiencing or witnessing biased or discriminatory events. The majority of these offenses were committed by patients, not faculty or other employees. The researchers largely interpreted most of the incidents as microaggressions.
From the interviews, the researchers identified six central themes. Among them: foreign fellows and US-born trainees being perceived or made to feel like outsiders; inappropriate comments being made toward female employees about their looks, credentials, or marital status; lack of action after reporting incidents or concerns that reporting such incidents would be futile; and strategies fellows used to cope after negative interactions.
One interviewee said, “I was fired by a patient because I have an accent.” Another said that when she is interviewing for jobs, she is always asked if she has children: “Maybe they’re asking in an innocuous manner, but I always feel like people worry. Is this person going to take maternity leave and be less available for work?”
For Warsame, “the idea that American citizens were frequently made to feel like they do not belong was surprising.”
Not surprising to Warsame, however, was the importance of fostering diversity and inclusion during fellowship years. Fellows often noted that greater diversity within the program helped create a more inclusive environment.
“[What’s] important to reinforce is the value of creating platforms for honest discussion and intentionally seeking fellows’ voices and perspectives, which in turn makes them feel like they belong,” Warsame said.
Still, the researchers found that fellows often did not report incidents of discrimination or bias. Only six trainees were aware of policies for reporting patient misconduct or discrimination, and only one ever reported an incident.
Where’s the Support?
For Duncan, her encounter 3 years ago with the patient with sunglasses wasn’t her first experience of discrimination on the job — or her last.
Although hurtful in the moment, she had the wherewithal to report the incident to her attending physician, who was equally shocked. Initially unsure of how to handle it, the attending ultimately stepped up and provided “immense support,” Duncan said
The issue was brought to the attention of the program director, who took swift action. The patient was documented as “disruptive,” informed of that status in writing, and was banned from receiving treatment from trainees at the center, although Duncan noted he still received the medical care he needed.
Often, however, fellows who report incidents of discrimination and racism receive little support. According to Warsame and colleagues, most trainees don’t bother reporting these experiences because they believe that doing so would be futile.
“Concerns about reporting included jeopardizing future employability, risk of retaliation, and challenges reporting experiences that could be perceived as subjective and difficult to prove,” the authors write.
For instance, one interviewee said: “I’m afraid to report these things because there’s gonna be repercussions. There’s no way it’s gonna be anonymous…. I just have to toughen up and, you know, get used [to it].”
Warsame added, “A major challenge for trainees was that they often felt unheard, and at the time, there was no formal debrief regarding discrimination issues when they arose.”
These instances of bias have implications for trainee well-being. In a 2019 study, discrimination that physicians and students experienced during training had adverse effects on their emotional health. Responses from 50 trainees and physicians revealed a wide range of discriminatory experiences, including patients rejecting care and spewing racist, sexist, or homophobic epithets. Many physicians were uncertain about how to respond effectively and appropriately.
Since that study was published and after having completed her own fellowship, Duncan said she has seen some change for the better.
“There is a lot more awareness around this, and programs are trying to do better in recognizing and responding to incidents,” she said. She noted that it’s important to ensure that those who are directly affected by discriminatory behaviors aren’t left to do all of the “heavy lifting” of addressing and resolving the issues.
The weight of discriminatory incidents, from microaggressions to overt racism, is cumulative and can adversely affect a person’s career. “It’s exhausting ― we need support,” she said.
The Mayo Clinic is working to ensure that trainees receive support. “The study has prompted communication workshops and faculty development to better equip trainees with strategies to address [and report] patients who behave or display disrespectful or discriminatory behavior,” Warsame said.
She and her colleagues noted that the anonymous hotline used for the survey cultivated a safe environment for candid discussions and that such an approach is “feasible and effective to explore sensitive topics and scalable to various geographic locations and different medical specialties.”
“We recognize that our program must seek this feedback regularly and ensure we keep a finger on the pulse of our trainees,” Warsame added.
JAMA Netw Open. Published online November 8, 2021. Full text
Warsame and Duncan have disclosed no relevant financial relationships. Duncan noted that her views and comments are her own and do not necessarily reflect those of her institution.
Sharon Worcester is an award-winning medical journalist at MDedge News, part of the Medscape Professional Network.
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