Exploring the Role of Race in Black Males’ Sense of Belonging in Medical School: A Qualitative Pilot Study

Abstract

The purpose of this qualitative pilot study was to investigate the role of race (and racism) and sense of belonging for Black men in medical school. A single research question guided this exploratory project: How do Black men in medical school describe their experiences? Analyzing interview data from 8 Black male medical school students revealed frequent encounters with racial discrimination and prejudice. Results show that race adversely affected their academic and social experiences and diminished their sense of belonging in medical school. Consequently, they faced difficulty connecting with White peers and faculty, racist stereotypes, and racial microaggressions that stigmatized them as "out of place," unqualified, or unusual. Implications for policy, practice, and minority medical student success are highlighted.

Introduction

Previous research on race in medical education has focused on three primary areas. There has been research on incorporating race and cultural awareness in core courses and teaching cases in medical school [1, 2]. For example, in a recent study, Allen et al. [3] evaluated a novel approach for incorporating cultural knowledge into the biomedical sciences through a gross anatomy course. Analyzing survey data from 21 students, they found that the pilot course yielded significant improvement in the overall cultural awareness of students, with largest gains in communicating with sensitivity and respect, as well as integrating cultural information into treatment plans.

Medical experts and clinical researchers have also directed attention to caring for patients from diverse racial and/or cultural backgrounds. For example, one study measured 1074 medical residents’ attitudes and perceived preparedness to care for patients from diverse sociocultural backgrounds [4]. They found that medical residents’ readiness to provide cross-cultural care to racially diverse patients was positively correlated with their attitude toward such care and their exposure to patients from varied backgrounds, although medical residents’ knowledge of health disparities was generally poor. Along with changing demographics in the United States (U.S.), results point to the need for “trained physicians [and medical researchers] able to deliver high-quality care to socioculturally diverse patients.”

Scholars have also examined racial/ethnic differences in medical students’ experiences, well-being, and perceptions [5]. For example, Butani et al. [6] analyzed qualitative and quantitative data from a survey of 114 medical students to assess racial differences in their experiences of professionalism. While Caucasian or White medical students were more likely than their non-White/ethnic minority peers to identify peer role models as effective teachers of professionalism, non-White medical students frequently reported unprofessional behaviors from faculty, staff, and administration in their interpersonal interactions. In another study, Dyrbye and colleagues analyzed survey data from 1701 students at 5 medical schools and uncovered high rates of racial discrimination (i.e., unfair treatment based on race), racial prejudice (i.e., negative opinions based on race), and feelings of isolation among minority medical students [5]. They concluded that race contributes to the distress experienced by minority medical students, and also stressed the need for “further research studies to identify and define the causes of these perceptions, [feelings], and to improve the learning climate for all students.”

Indeed, with few exceptions, little is known about the training experiences of ethnic minority medical students. And while academic and social difficulty among minority students during medical school has been investigated [e.g., 5, 6], the ways in which race (and racism) shape the “lived experiences” (hereafter, "racialized experiences") of African American male medical students remain largely unexamined despite prevailing evidence that race adversely affects medical school experiences especially among African Americans who “may have overcome substantial…challenges before matriculation” [5]. In fact, there are concerns that the health care profession is “often silent on the issue of race” [7]. This is the gap addressed by the present study, focusing on the role that race plays in the academic and social experiences of Black men in medical school, in hopes of breaking the silence and giving voice to those whose perspectives are all-too-often marginalized, minimized, or dismissed as "too few in number" to matter.

Purpose

The purpose of this qualitative pilot study is to investigate the role of race and racism in shaping the academic and social experiences of Black men in medical school. A single research question guided this exploratory project: How do Black men in medical school describe their experiences related to race?

Method

This study is part of a larger research program focused on examining the academic, social, and professional experiences of ethnic minority men (i.e., “men of color”) in graduate and professional education [8]. Whereas the larger project is comprised of both quantitative and qualitative data from masters, doctoral, and professional (i.e., medicine, law, theology) students, this brief report is based on analysis of interview data from medical school students only.

Sample

Participants included eight (8) African American males, a stereotyped and socially marginalized group [9], enrolled in a predominantly White medical school in a mid-Western state, with just over 600 students. Demographics of the general student body at the medical school include 60% White, 21% Asian, 5% Hispanic, and 4% Black, with the balance identifying as “multiracial” or “non-resident,” according to the institution’s profile. The vast majority of faculty are White (80%); only 2% are Black. Despite a small Black student and faculty population, the medical school is highly ranked and offers cultural awareness training, predoctoral fellowships, and heritage festivals through a centralized diversity office.

Among the study participants, five students were pursuing an “MD” and three were pursuing a “PhD,” although all took courses in medical science(s). The average age of participants was 27 years old. Table 1 presents additional information about the group.

Table 1.

Description of the sample (N = 8)

Characteristic
Age (average)	27 years
Year in medical school
-First year -Second year	63% 37%
Undergraduate institution
-PWI -HBCU	38% 62%
Earned a Master’s degree
-Yes -No	25% 75%
Ethnicity
-African American -African -Haitian -West Indian	50% 25% 13% 13%

NOTE. PWI =predominantly White institution; HBCU =historically Black college and university. Numbers may not round to “100” due to rounding.

Data Collection/Analysis

During a larger assessment effort at the medical school under study, qualitative data were collected using a focus group facilitated by the author. The focus group lasted 90 minutes, providing time for personal introductions, mutual sharing, and vivid, illustrative examples to clarify the meaning and significance of comments shared in the session. A semi-structured interview protocol was used to assess medical student experiences and perceptions. Follow-up probes were used to elicit specific information about the role of race and racism in shaping their experiences. Additionally, participants completed a short demographic survey that provided information about their age, ethnicity, and background.

Qualitative data were analyzed in stages using the constant comparison method as described by Strauss and colleagues [10, 11], after interviews were transcribed by a professional and entered into NVivo®, a qualitative data analysis software. At one stage, interview data were analyzed using frequencies and descriptive statistics, where appropriate, to assess how often certain words and phrases appeared in the transcript. Although specific steps of constant comparison were not formally adopted as rigid methodological prescriptions, analysis was conducted in a manner consistent with underlying principles related to rigor, repetition, and contrast. This approach has been used in a prior study [12].

Findings

Three major themes were identified using the analytic process described. First, Black male medical school students reported frequent encounters with racial discrimination, racial prejudice, and “felt like race adversely affected their medical training,” using the words of one participant. Second, Black men in this study described how their racialized experiences negatively affected their perceived sense of belonging in medical school. Lastly, they explained vividly how their academic and social experiences made it difficult, at times, to connect with peers and faculty, resulting in social isolation, compromised confidence, and missed opportunities for professional advancement and development.

Frequent Encounters with Race and Racism

Every single one of the 8 men in this study reported “encountering racial discrimination” in medical school on the demographic form—that is, 100% of the sample. In the group interview, however, they explained the nature of such occurrences, ranging from overt to more subtle forms of racial discrimination and prejudice. For instance, Marcus and Daylon (pseudonyms) spoke at length about “faculty getting them confused…calling [them] by each other’s names.” Wallace went on to say: “There aren’t many of us [Black males] here in the first place…they can’t get our names right?! Damn.” Their comments reveal a troubling consequence of such marginalizing experiences. Participants seem to internalize what might seem to some like “innocent mistakes or errors” as “pretty clear signals that [Black men] really [emphasis added] don’t matter…[they] don’t belong [in medical school],” as one put it directly. This also exposes the ways in which presumably innocuous, race-neutral incidents can perpetuate racial invisibility, racial harm, and racial microaggressions, defined as "commonplace daily verbal, behavioral, or environmental indiginities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color" [13].

Racism Negatively Affects Belonging

Another example of racial discrimination that negatively influenced Black males’ perceived sense of belonging in medical school related to how others—especially White faculty and campus personnel—prejudged them and their role at the institution. For example, two guys shared the following anecdotes:

I’ll never forget it…when I first got here at [institution], I mean my very first day, Dr. [Hidden] saw me in the hallway and was like, ‘Wow, [are] you new on the basketball team? We’re definitely going to the championship this year (laughing).’ I mean, yeah, I’m 6 [feet] 3 [inches] but I did not come here for b-ball…I came for medical school. And it’s like they cannot even imagine that. (Chaz).

Yeah, it’s a lot of experiences like that. People always assuming you are here only because of affirmative action. Or that you were in the premedical [diversity program]—I mean, it’s a great program…do not get me wrong, but I got admitted based on my grades and MCAT scores just like everybody else. I’m African, yes…but not stupid, not barely scraping by, and not flunking out. (Kedron).

Both Chaz and Kedron joined the others in recalling negative encounters with racial discrimination, prejudice, and microaggressions such as racist joking or heightened surveillance that catalyzed a reexamination of previously held beliefs about their academic standing and sense of belonging in medical school. Several of them referred to “crazy checks,” where they would ask each other: “Am I crazy?” “Did that really just happen to me?” Racist misperceptions or racially-charged incidents (e.g., being unduly interrogated by campus securuity) triggered hyperconsciousness of one's race and anxiety about participants' place and positioning in medical school. Reconsidering previously held beliefs in this way raised self-doubts about their abilities, reduced their sense of belonging in medical school, and made it difficult, at times, to connect with White peers and faculty who might subscribe to such negative beliefs and low(er) expectations about Black students.

Connecting with Peers and Faculty

Participants spoke at length about the ways in which their racialized experiences diminished their sense of belonging—or “fit”—in medical school, affirmed cultural differences between them and others on campus, and made it difficult to connect with White peers and faculty at times. Sometimes this was due to a “residual effect” of negative encounters experienced elsewhere. Jonathan referred to a “tenuous relationship” between him and a medical school professor who “has a history of poorly evaluating students of color…no matter what they do.” He offered vivid examples of how he “went above and beyond expectations to ace the genetics course, but barely passed [emphasis added].” When he asked the instructor for feedback, all he received was: “Don’t worry…lots of Blacks—not people of color, but Blacks—struggle in this class. They just can’t seem to grasp it.” That infuriated him, but he never told another professor or administrator at the medical school because he believed “they wouldn’t do anything…except probably kick me out for complaining (laughing).” Instead, Jonathan and his focus group peers shared how such racialized experience compelled them to work harder in hopes of "proving them [White peers and faculty] wrong" or at least avoiding confirmation of a prevailing stereotype about Black medical students.

Although MD and PhD students in this pilot study shared a number of experiences in common, there were important nuances. For example, PhD students spoke extensively about how race seemed to shape their relationships with their doctoral advisors who were “all White,” as participants described. MD students, on the other hand, talked about negative or “awkward moments” in the classroom with White faculty discussing poverty, genetics, and health disparities in medical practice. MD students in the present study also felt like race played a “significant but invisible” role in their experiences with clinical supervisors, preceptorships (i.e., shadowing), and even admission interviews. Black men in this study exposed how their status as medical students did not afford them immunity from racial microaggressions, gendered stereotypes, and the psychologial fatigue that results from exhausting one's facilities to prove others wrong.

Feeling like others considered them “less intelligent” or “less qualified based on [their] race” left the Black men in this study frustrated with being unfairly stereotyped and “out there on their own,” as Trent put it. Participants rarely hung out with some White peers, “unless absolutely required for a class.” And they tried to avoid White faculty who were “known for not treating minorities fairly…or even if they published stuff against health disparities and [the] like.” Participants explained, however, that sometimes this limited their access to prestigious fellowships, residencies, or “training ops [opportunities] where these guys [White faculty] were like the gatekeepers.” This seemed to be particularly detrimental for MD students in gaining highly sought residencies and for PhD students in terms of medical fellowships, grants, and research/publication opportunities deemed important for their professional socialization and career advancement.

Discussion

The purpose of this pilot study was to investigate the role of race and racism in the academic and social experiences of Black men in medical school. Findings suggest a number of important conclusions that deserve discussion. First, results from this study suggest that race adversely affects the experiences of Black males in medical school. While this corroborates findings presented elsewhere about the frequency of racial discrimination for “non-White” or minority medical school students in general [6], the present study breaks new ground revealing, in relatively vivid details, the lived, racialized experiences of Black men in medical school specifically. Negative racial encounters diminish Black males’ sense of belonging in medical school, despite good grades and high MCAT scores. Feeling socially and psychologically isolated from or prejudged by mostly White peers and faculty made it difficult for Black men to connect with others in medical school, thereby restricting access to career-advancing opportunities and reducing the availability of support systems and networks that could advance their professional goals and medical school success.

The pilot study has implications for a number of constituent groups in medical education. For example, medical school faculty might consider these results when working with Black men. It’s clearly important to learn all students’ names, as it enables communication in formal and informal settings. But results from this study indicate that confusing Black men’s names or mistakenly calling them by the wrong name is internalized by some students as a sign or signal that they do not matter, are insignificant, invisible, and do not belong. Lack of belonging has been shown to hijack one’s academic abilities, erode intellectual confidence, and compromise performance in high-stakes academic settings [14]. Beyond learning students’ names, medical school faculty should be trained in cross-cultural advising, implicit bias, and avoid racial microaggressions that could adversely affect Black males.

Directors of premedical diversity programs might also benefit from this study. Results point to the important role that such programs play in serving as a “pipeline” into the medical profession for historically underserved populations. But participants also alluded to stigma associated with being part of what others perceive as “affirmative action” programs. Medical school deans, program directors, and diversity officers should work actively to dispel such myths by publicly acknowledging the importance of diversity, inclusion, and equity, while celebrating the academic achievements of ethnic minority students and faculty with regular cadence. To combat social isolation, medical school staff should invest in student organizations and liaisons who provide a supportive network for minority students, help them adjust to medical school, and connect them to resources when they experience difficulties like those described herein. Cohort-based programs that move students through medical school by sequencing coursework and ensuring racially diverse students are not “the only” may also be helpful for addressing problems of isolation, alienation, and loneliness.

Medical schools need to be aware of the nature of relationships between students and faculty, as well as the prevalence of racial discrimination experienced by minority students. This significantly influences their ability to recruit and retain students (and faculty) of color. Yet, relatively few schools have systems in place to conduct such monitoring [15]. Based on the results of this study, medical schools, especially offices of minority student affairs, should periodically review all performance evaluations of (minority) medical students to discern evidence of overt or subtle patterns of discrimination over time. Deans and department heads are advised to implement anonymous bias reporting systems where students can place complaints of incidents related to racial discrimination, prejudice, harassment, and other forms of oppression without fear of reappraisal. Incentivizing purposeful engagement between medical school faculty and ethnic minority students through structured mentoring programs or professional communities may also prove effective in reducing the social distance between White faculty and Black (male) students, which in turn, has been shown to reduce racial bias, alter stereotypes, foster trust, and increase sense of belonging [14].

Despite these insights, this pilot study, like all others, is subject to several limitations, primarily related to the modest sample size. Although the 8 Black men in this study represent 100% of Black men enrolled in the medical school under study at the time of data collection, the number is too small to assure maximum variation of perspectives or saturation of responses. This delimits the scope of the study and may introduce a source of bias in unknown ways. Second, the study is limited in that it is based on a single institution. The institution under study is best described as a highly selective, predominantly White medical school and, thus, findings likely do not transfer to medical schools that are more racially diverse, less selective in terms of admissions, or minority-serving such as those at historically Black colleges and universities (HBCUs). While important, these limitations do not remove the relevance and significance of findings from this pilot investigation.

Further research is needed on larger samples, multiple institutions, diverse institutional types, women, and racially diverse samples that permit comparison of experiences/perceptions across White, Asian, Hispanic, Black, and multiracial medical students. The limited data available about minority medical students’ experiences is particularly problematic for policymakers, education administrators, and researchers who need such intel for decisionmaking. Lack of high-quality data, especially large-scale datasets, undermines efforts to develop, assess, and implement scalable interventions that might facilitate belonging and improve medical student success, especially Black males. Without such critical insights, educational leaders and medical science educators are likely to allocate limited resources to interventions and programs that produce little gains. Federal agencies, like the National Institutes of Health, and medical associations should support the development of major national surveys, multi-institutional research teams, and collaborative intervention projects through R01 grants, limited submissions, and special contracts.

Conclusion

I conclude by encouraging medical educators, administrators, and other researchers to capitalize on the contributions of this small pilot study by accepting these perceptions as real, even if for only these 8 Black male medical students, although the weight of existing evidence shows that it's far more prevalent than most believe and remains largely obscured in the literature. Lean in for understanding and conduct further research to gain insights that, no matter how difficult to admit or accept, are vital for future initiatives. By acknowledging and addressing how race and racism affects Black male medical students’ experiences, we are promoting student success for all.

Funding

This study received funding from the National Science Foundation (US), Education and Human Resources (EHR) CAREER Award #1132141.

Compliance with Ethical Standards

Conflict of Interest

The author declares that he has no conflict of interest.

Ethical Approval

Not applicable.

Informed Consent

Human subjects approval (expedited) by Institutional Review Board. All participants were provided informed consent for the study.