Pertinent Advice For Black Residents
This is a summary of the experiences of one group of residents at a U.S. Institution. It is by no means scientific, but I believe that the purpose of it is to document the common feelings among African American physician residents. I found my own experiences to be very similar to many of those described. My hope is that this article will at least help African American residents know that your perceptions of what's going on is most likely more than just your imagination.
This article shares a lot of similarities with the one above it. Here, the focus is on the experiences of Black attending physicians and how they deal with the racial dynamics of the average American hospital.
A discussion of Solo Status, being the only one of your social group, and how it impacts the performance of women and minorities in the classroom and workplace.
A discussion of the ubiquitous yet often invisible nature of racial microaggressions in everyday life, and the impact that they have on minorities.
Whether racism is the reason for the percieved hostility against you or not, there's a good chance that the method used to take you out very closely resembled sham peer review. This article did an exceptional job of capturing the emotions, frustrations, and consequences of the prolonged legal battle that I am still waging against my oppressors. Anyone who has shared my experience will recognize the truth written here.
This is probably the most important piece of literature that I have found on the topic of race and residency. Print out the abstract, send it to a friend or a program director, and buy the author's book from Amazon.com. In 2001, PhD candidate Virginia Adams O'Connell published her dissertation titled 'Attrition in Surgical Residency Programs.' In 2007, she published a book titled 'Getting Cut' which contains the same data in a more reader friendly format. She reviewed data from 556 residency programs in general surgery, orthopedic surgery, anesthesia, neurosurgery, and plastic surgery, and conducted 75 interviews with attending physicians, residents, and nurses from 5 neurosurgery programs. She found that white women and racial minorities have a greater risk of attrition, and attributes this to the fact that they tend to have fewer and poorer interactions with program faculty. She noted that this attrition risk is elevated across all specialty residencies studied, even when controlling for objective measures of performance.
"About three out of every one hundred residents who begin their surgical residency training were fired before completing their programs. Just as we found for resignations, however, this rate varies based on the resident's race and gender. While overall risk three percent, the risk for white females, however, was five percent, for non-white males was 20%, and for non-white females, it was 23%. Therefore, white females were 2.5 times more likely to be terminated than white males, while non-white males were 8.74 times more likely, and non-white females were 9.87 times more likely."
Her recommendation is that the medical profession review the evaluation system for potential abuses. Anyone reading this webpage already knows these facts to be accurate of course. Proving it, and overcoming the white male power structure's tendency to deny these facts is the real challenge. I think that this dissertation/book can help in some way. I find it very strange that I scoured the internet for resources for 4 straight years, but did not find this until someone told me about the book. Makes me wonder if there has been an intentional effort to silence this message.
Published in Academic Medicine, Vol. 70, No. 12/December 1995
Data from this study came from the American Medical Association survey of the 1991-92 residency year, in which program directors were asked for information about residents who had taken extended leave or had withdrawn or been dismissed from their programs prior to completion. Data was reported on 89,368 residents across 6,302 residency programs. During the 1992 year 2.7% of residents withdrew or were dismissed from their programs and 1.0% took extended leave. The most concerning results:
"Examination of loss and attrition by race and ethnicity demonstrated substantial differences across categories. Overall, Caucasians were significantly less likely to withdraw than were those from other groups. While African American, Hispanic , and Asian residents were twice as likely as Caucasians to have withdrawn or been dismissed for performance difficulties, rates of extended leave for performance difficulties were over eight times higher for African Americans and Hispanics than for Caucasians."
Published in American Journal of Obstetrics & Gynecology November 2008
The authors were looking to identify risk factors for attrition among obstetrics and gynecology residents. They analyzed 2001-2006 American Medical Association Graduate Medical Education (GME) Census data for all residents who entered obstetrics and gynecology in 2001. Of 1055 residents entering OB/GYN in 2001, 21.6% were in the attrition group. 133 changed residency programs or graduated off-cycle, 75 changed specialty, and 20 discontinued GME. Residents who were older, underrepresented minority race, Asian race, osteopathic or international medical school graduates were more likely to be in the 'attrition' group.
Attrition in Graduate Surgical Education: An Analysis of the 1993 Entering Cohort of Surgical Residents
Published in Journal of American College of Surgery Vol 189, No. 6, December 1999.
For this study, the authors collected data from the AMA's Medical Education Research Information Database, the American College of Surgeons Resident Masterfile, and The Association of American Medical Colleges GME Tracking Census database. The data were examined by specialty, gender, ethnic background, and type of medical school attended. The results demonstrated an overall attrition rate from surgical GME was 12%, the rate for international medical graduates was 33%, and the rate for osteopathic residents was 28%. African-American and Canadian graduates had attrition rates of 16% for men and 8% for women. Hispanic United States and Canadian graduates had attrition rates of 14% men and 15% for women. General Surgery residents had an attrition rate of 26% which included residents in undesignated preliminary positions. Comparing Caucasian US Allopathic residents to African-American US Allopathic grads the study demonstrated that 183/2,358 Caucasian males (8%) fell into the attrition category while 20/124 (16%) of African American Males fell into this category. In this cohort, being an African American male left you twice as likely to leave residency prematurely. Comparing US Allopathic residents to Hispanic US Allopathic grads you that 183/2,358 (8%) White males fell into the attrition category, while 15/110 (14%) of Hispanic males suffered attrition. The disparity between African American/Hispanic Allopathic grads and White Allopathic grads highlights the effect that race has on outcomes. But perhaps the most dramatic difference is the fate suffered by male IMG residents. White IMG residents suffer attrition at a rate of 27% (183/2193) while the Asian Male IMGs saw a rate of 41% (40/423).
STRATEGIES FOR BLACK RESIDENTS
Although most Black Residents who have happened upon my site already know that the cards are stacked against you, I have assembled an abundance of articles above to establish that it is indeed factual that something about residency training is making it harder for black residents to complete their training. I outright reject the intellectual inferiority and 'affirmative action must have taken you as far as it can' arguments simply because the licensing board exams don't care what race you are. So in other words, Black residents are able to graduate from medical school, but find themselves being terminated at higher rates even when you control for objective performance measures.
I would have found a lot of comfort seeing all of the facts laid out like this when I was going through my trials and tribulations. I attempted to have an open, honest conversation with my staff about race and how I thought it was impacting my situation. This made them angry, and put the focus back on me as a person without insight who was in denial about their ability to perform. It would have been nice to be able to show them that this sort of thing happens, and race does have an impact on outcomes in GME.
My hope is that the Black residents reading this will actually be encouraged and not fall into despair when you see that this phenomenon has been well documented. I often thought of this as 'the final struggle for equality.' Several generations ago, our ancestors just wanted freedom from slavery. Then our grandparents wanted to stop getting lynched. Our parents' generation were looking for equal access to education, banks, jobs. And our generation is struggling to establish acceptance, not just access, in elite professional occupations. Because we are not completely accepted, we are mentored less, criticized more, and easily discarded when something goes wrong. You must struggle, and you must prove yourself right now in order to advance that acceptance just another inch, maybe just another millimeter. That is what I would tell myself every morning when I was in the thick of it. Those before us took physical and emotional beatings, now we must endure emotional and intellectual beatings as we do our part for the group. Stay strong, and browse over my recommendations below.
(1) Seek out residencies that are racially diverse. This can be difficult if not impossible for some specialties and geographic regions. I cannot support this recommendation with evidence, but it seems intuitive that more minorities in a program would reduce or eliminate your solo status and all of the negative experiences associated with it.
(2) Seek out a mentor (of any color) within your department. A mentor can help you improve on weak areas, provide some moral support, and most importantly, be your advocate when things start to get rough in the residency.
(3) Always bring your 'A' game. Easier said than done when the sleep deprivation and endless work hours start adding up. A healthy diet, dependable partner, good sleep habits, and solid motivation can really contribute to success. The In-Training exams are one of the few truly objective measures of resident performance that are almost universal. Aim high on this exam each year. I have reviewed two lawsuits involving black residents claiming discrimination where their in-training exam scores were found to be very low. The residency program effectively used this against the resident in both the institutional and the legal proceedings.
(4) Accept that it will be unfair, but never embrace a defeatist attitude. If you give in to self-pity or anger, it's completely possible that your own emotions will do you in. It can be difficult, but you have to place your focus on the things that you have the power to impact.
(5) One of the ways that I experienced discrimination was through the thorough documentation of my mistakes, and the relative silence regarding other residents' mistakes. My solid performances were quickly forgotten or minimized. The best way to neutralize discriminatory behaviors is to ensure that both your successes and failures are equally documented. A daily evaluation form for the clinic, morning report, and/or the operating room is a good way to implement this. When your performance is recorded each day, it is more difficult for supervisors to justify biased evaluations of an entire month or rotation. Although I see this as an excellent defensive measure, you can justify it's use to your supervisors by emphasizing your appreciation for feedback as a developing clinician.
(6) Based on my review of the legal cases involving residencies, and minorities suing because of racial discrimination, I believe that there is a 99% chance that suing your hospital/residency will be a waste of time/money/emotional energy. It pretty much fails every time. Your best bet is to just walk away, and start working on your plan to rebuild/reinvent yourself. You rose once before, and you will rise again.
(7) Court cases tend to be won by proof of some absolutely sinister intentions. An email chain containing inflammatory dialogue, a voice recording, or something that is obviously retaliatory or malicious. If you believe that you have an abundance of evidence in support of your case then consider contacting an attorney who specializes in employment law. I have added a page with Attorney recommendations here. I'll try to get it filled up as quickly as I can.
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