A Narrative Review of Discrimination Experienced by Medical Students

Abstract

Introduction

The aim of this review was to clarify the nature of discrimination experienced by medical students and identify institutional responses and directions for future research.

Method

A narrative literature review of first-hand experiences of discrimination reported by medical students across a 10-year time period.

Results

Twenty-five reports with different methodologies were included. Discrimination was defined by a wide range of terms. Students had a range of responses to discriminatory treatment and many did not report their experiences.

Conclusion

Discrimination is a significant issue for medical students in clinical settings. Further research is needed to formulate institutional responses to understanding and addressing discrimination.

Introduction

The definition of discrimination is a bias or prejudice resulting in denial of opportunity or unfair treatment. Medical school is an institution rife with hierarchies of power, where discrimination can be inadvertently perpetuated [1]. Discrimination may be direct, overt or disguised [2] to the extent that students may doubt their experiences and judgement of it.

The “hidden curriculum”, distinct from the formal curriculum, refers to the tacit communication of the culture of medicine rather than the transmission of knowledge and techniques [3, 4]. The hidden curriculum is a form of socialisation as students develop a professional identity as members of the medical profession. This may be part of students’ moral enculturation as they are role-modelled values and attitudes by senior clinicians and peers. The increasing awareness of unconscious bias [5] has led to formal tutelage in medical curriculums about deconstruction, the act of challenging assumptions about stereotypes and behaviours that affect a patient’s access to treatment [6]. Despite this, students find it difficult to identify discrimination as they may consider the experience to be a matter of perception.

A narrative review of the literature was conducted with respect to perceived discrimination experienced by medical students in clinical settings. This form of review was chosen [7] to explore contextual influences underlying discrimination in preference to quantifying evidence or establishing the efficacy of a proposed intervention [8]. The aim was to clarify the nature of discriminatory experiences with a view to guiding research on institutional responses to address discriminatory treatment in medical school settings.

Methods

Search Protocol

An online literature search of four databases (Medline, Embase, Informit and ERIC) was conducted on 18 January 2018, using variations of MESH terms that encompassed a broad array of discriminatory experiences: prejudice, sexism, homophobia, racism, ageism, stereotyping, bias, harassment and abuse (Table 1). Our inclusion criteria were direct, first-hand discriminatory experiences of medical students; clinical settings; empirical data; systematic literature reviews containing empirical data; English language; and from 2006 to 2017. Studies of residents and advanced subspecialty trainees were excluded.

Table 1.

Medical subject headings used in search

Medline Subject Headings (MeSH)	Keywords
Students, Medical/	(medic* adj2(student or students))
Education, Medical, Undergraduate/	(undergraduate* and medic* and (education or program*)) ((intern or interns* or trainee or trainees) and medic*) House officer*
Discrimination (Psychology)/	Discriminat*
Prejudice/	Prejudice*
Sexism	(sex* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-trea* or illtreat* or ill-treat* or agress* or aggress* or persecute* or aggravate* or violen* or bias* or intolerance* or favo?rit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*)) (gender* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-trea* or illtreat* or ill-treat* or agress* or aggress* or persecute* or aggravate* or violen* or bias* or intolerance* or favo?rit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*)).tw.
Homophobia/	Homophob*
Racism/	(racist or racist) (racial* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or persecute* or aggravate* or violen* or bias* or intolerance* or favorit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*)) (ethnic* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or persecute* or aggravate* or violen* or bias* or intolerance* or favorit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*)) (culture* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or persecute* or aggravate* or violen* or bias* or intolerance* or favorit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*))
	(religi* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or persecute* or aggravate* or violen* or bias* or intolerance* or favorit* or inequit* or unfair* or bigotr* or injustice* or marginali* or insensitive* or exploit*))
Stereotyping/	Stereotyp*
Ageism/	(Agist or ageist or agism or ageism)
	(physical* adj2 (abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or violen* or exploit*))
	(verbal* adj2 (abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or violen* or exploit*))
	(academic* adj2(abus* or harass* or assault* or maltreat* or mistreat* or mis-treat* or illtreat* or ill-treat* or cruel* or hostil* or harm* or hurt* or agress* or aggress* or brutal* or injur* or violen* or exploit*))

Data Analysis

Search results were imported into a reference manager and duplicates were removed. The titles and abstracts were independently screened by two reviewers (LN and CL) for eligibility. Relevant full text articles were retrieved and excluded if they did not contain empirical data [9] or if they did not specifically refer to discrimination [10–16].

To establish the narrative framework, categories emerging from the findings of the studies were generated using an inductive approach [17]. All authors agreed upon on the key facets derived from the articles. PRISMA guidelines were used to identify relevant articles (Fig. 1).

Fig. 1.

Flow diagram used in search strategy

Results

The initial search yielded 2332 articles. The title exclusion process reduced the articles to 2124, which resulted in the detailed reading of 208 abstracts. A total of 173 articles were excluded based on this analysis. The full texts of 35 articles were read thoroughly. Ten were further excluded resulting in 25 articles for the final review (Table 2).

Table 2.

Summary of article reviewed

First author (Year)	Country of Study Conduct	Study Design	Definition of Discrimination
Frank (2006)	USA	Longitudinal	Harassment, belittlement
Nagata-Kobayashi (2006)	Japan	Cross-sectional	Abuse
Wilkinson (2006)	New Zealand	Cross-sectional	Adverse experiences, sexual harassment, gender and race discrimination
Wear (2007)	USA	Focus groups	Sexual harassment
Ahmer (2008)	Pakistan	Cross-sectional	Bullying
Rademakers (2008)	Netherlands	Cross-sectional	Sexual harassment
Garvey (2009)	Australia	Focus groups	Discrimination
Haviland (2011)	USA	Cross-sectional	Mistreatment
Rees (2011)	UK	Interviews	Abuse, sexual harassment, discrimination
Alzahrani (2012)	Saudi Arabia	Cross-sectional	Bullying and sexual harassment
Babaria (2012)	USA	Interviews	Sexual harassment, gender discrimination
Fried (2012)		Longitudinal	Harassment, mistreatment
Hashmi (2013)	Pakistan	Cross-sectional	Gender discrimination
Norman (2013)	Ghana	Cross-sectional	Sexual harassment
Orom (2013)	USA	Systematic Review	-
Fnais (2014)	Canada	Systematic Review	-
Iftikhar (2014)	Saudi Arabia	Cross-sectional	Abuse
Bruce (2015)	USA	Cross-sectional	Gender discrimination
Wimsatt (2015)	USA	Cross-sectional	Discrimination
Zahid (2015)	Malaysia	Cross-sectional	Discrimination in obstetrics and gynaecology
Ahmadipour (2016)	Iran	Cross-sectional	Mistreatment
Hardeman (2016)	USA	Longitudinal	Discrimination
Kristoffersson (2016)	Sweden	Focus groups	Gender stereotypes, discriminatory treatment
Peres (2016)	Brazil	Cross-sectional	Mistreatment
Siller (2017)	Austria	Cross-sectional	Mistreatment

The review identified four concepts across the studies [18]: (i) terminology of discrimination; (ii) methodology; (iii) prevalence; (iv) types of discrimination; and (v) student responses to discrimination.

• (i)The terminology of discrimination

Defining experiences related to discrimination was inconsistent due to the broad range of medical students’ experiences [19]. Discrimination may be perceived and subjectively judged by individuals [20], based on gender, sexuality, ethnicity or disability. Experiences of discrimination were incorporated into behaviour that included mistreatment, abuse, harassment and bullying [21]. Harassment was defined as “unnecessarily harmful, injurious or offensive treatment inflicted by one person upon another” [22].

Mistreatment was defined as behaviour that “shows disrespect for the dignity of others and unreasonably interferes with the learning process.” Examples included discrimination based on race, religion, ethnicity, sex, age or sexual orientation. [23]. The experience of mistreatment was based on student perception [23].

Bullying was defined as “persistent behaviour against an individual that is intimidating, degrading, offensive or malicious and undermines the confidence and self-esteem of the recipient” [21, 24]. Types of bullying included verbal mistreatment and threats to professional status [19].

Abuse was defined as “the violation of one’s human and civil rights, or action or deliberate inaction that results in neglect and/or physical, sexual, emotional or financial harm” [19] or “unwanted, harmful, injurious or offensive acts directed at someone by another” [25]. Some authors considered that abuse rarely escalated to bullying [25].

Gender discrimination was defined as “gender based behaviour, policies and actions that adversely affect work by leading to disparate treatment” or an” intimidating environment” [26]. Sexual harassment was defined as verbal and nonverbal behaviours such as gender harassment, unwanted sexual attention and sexual coercion [27]. Gender harassment included insulting, hostile and degrading behaviour, indications that female students were less worthy of attention than males [27] or “unwelcome sexually oriented attention” [28].

• (ii)Methodology

Cross-sectional surveys were a common method to identify abuse and mistreatment [19, 20, 22, 24, 29–32]. Students provided qualitative descriptions of experiences [25, 27, 28]. Some studies gave students examples of abuse to classify their experiences [20]. Sample size and response rates varied [26]. Limitations in sampling included students with homogeneous backgrounds, recall bias and the use of self-report.

Qualitative studies used individual and focus group interviews of smaller samples [25, 33, 34]. Qualitative analysis included grounded theory [30, 33] and thematic analysis [25, 34]. Qualitative methodologies gave students opportunities to express perceptions, examples, responses and ways of dealing with discrimination [34, 35].

The search yielded two literature reviews of harassment and discrimination in medical training, on the basis of race [36, 37] and gender [36].

• (iii)Prevalence

Mistreatment of medical students was widely reported [22, 29, 32] but not necessarily attributed to discrimination [32]. Adverse experiences increased with successive years at medical school, upon entering clinical settings. Students commonly witnessed discrimination (of any type) toward other students and negative role modelling by medical educators [38]. Students reported mistreatment based on discrimination due to gender, ethnicity, religion or age [19, 39]. Discrimination based on gender was often evaluated separately [39]. Negative role modelling included disparaging remarks or jokes about patients based on ethnicity, gender and body habitus [38]. Female students more frequently reported gender discrimination [20] with different types of perpetrators [39], both male and female [26].

• (iv)Types of discrimination

• Racial discrimination

Discrimination was experienced as overt and subtle. Students observed racist remarks, derogatory labelling and experienced differential treatment [25, 35, 38]. Students of indigenous ethnicity perceived negative expectations about their ability to succeed. Some felt a need to justify themselves against criticisms such as gaining entry to medical school based on a quota system [35].

• Gender discrimination

Gender discrimination included perceived barriers to job progression, lack of respect, sexual harassment, inappropriate verbal exchanges, barriers to hiring, bias against pregnancy and disparities in salaries or benefits [30]. Both men and women reported sexual discrimination [25]. Women reported unwanted sexual attention from patients, supervisors and staff [25, 28]. Women were restricted in opportunities to participate and not given the same opportunities as men to complete tasks [20, 34]. They perceived negative impacts on job satisfaction, self-efficacy, respect and career advancement. Women perceived a greater risk in reporting sexual harassment to the organisation [39]. Male students witnessed unfair or patronising treatment of female peers [25, 34]. Male students reported discriminatory treatment during placements in obstetrics and gynaecology [34, 40]. There was evidence of progressive desensitisation toward inappropriate behaviour as female students systematically tolerated gender discrimination throughout the course of medical training [33].

• Discrimination relating to mental illness

Students perceived there was a stigma in having a mental illness, which [41] was associated with personal weakness, devaluation and social or professional discrimination. Many students indicated they thought revealing their illness would negatively affect professional advancement [41].

• (v)Students’ responses to discrimination

Experiences of discrimination were described as negative or problematic [34]. Personal reactions included anger, fear, anxiety, depression and psychological trauma [20, 31], with variable impacts on learning [20]. Students avoided the person or the department or became isolated or withdrawn [22]. Students felt vulnerable [33] and dependent on supervisors and staff [34]. They were unsure of how to act and doubted their judgements [27, 28]. Some minimised their experiences [28, 33]. Positive consequences were less common but included acquiring assertiveness, motivation or promoting personal development [22].

Students were reluctant to report mistreatment and discrimination [25, 27, 29, 33]. There was a discrepancy between adverse experiences and reporting, for example, one study reported 90.9% of students perceived abuse during their time at medical school but only 14.8% reported it [19]. This discrepancy may reflect students’ concerns about reporting adverse experiences: they did not think it would accomplish anything [27, 29], did not know who they should report to and considered it more trouble that it was worth [19]. They also had concerns that reporting would affect their evaluations [27], would not be kept confidential or dealt with fairly [19] and potentially damage their careers [19]. Women were more likely to seek help [22] but perceived there was greater risk in reporting sexual harassment [39]. Students did not report sexual harassment as they were embarrassed, afraid, did not know if they would be believed and did not know whom they should tell [31]. Some thought the experience of abuse was their fault [25].

Some students dealt directly with the problem themselves [19]; others were empowered by speaking up and protesting discrimination [34]. Students who had reported experiences of mistreatment were less likely to pursue a career in that speciality [22, 23, 40].

Discussion

Discrimination is widely experienced but underreported by medical students. We were drawn to three key concepts: discrimination is consequential; discrimination occurs within a hierarchy of power; and institutional responses to discriminatory attitudes and treatment are not well defined. These concepts inform discussion for future directions for research to address discriminatory treatment in medical school settings.

Discrimination Is Consequential

The experience of discrimination is significant and consequential. Unfair treatment compromises learning and impairs the emotional development of future doctors [1]. Students report less confidence, a lower internal locus of control and decreased professional satisfaction [42]. Negative long-term impact was described as a transgenerational legacy, where mistreatment is perpetuated by those by who have been mistreated [43].

Discrimination Occurs Within a Hierarchy of Power

Medical students engage in a complex series of encounters when they enter clinical settings [3]. They acculturate to their new learning environment [28] and the hidden curriculum [38], observe and participate in dynamic interactions at different levels, and become aware of power differentials within the medical hierarchy. Discrimination experienced by students from other students (as individuals or groups) was not reported in the literature. This may reflect students’ concerns about the ultimate task of graduating as a doctor and awareness in medical institutions of student vulnerability to discrimination by academic and clinical staff. The fact that supervisors directly influence the grades student receive may hinder reporting of discrimination.

As students adopt a professional identity, they learn to deal with colleagues who do not behave well [28]. They may perceive discrimination to be normal [12] and become desensitised to inappropriate behaviour [33]. They may experience subtle preferential treatment or witness their peers being discriminated against. The failure to report discrimination and mistreatment may be related to fear and disempowerment in a hierarchical organisational culture [10]. Students are dependent on senior staff for supervision and evaluation. This creates powerful incentives to staying silent and not challenging norms when facing negative treatment arising from discrimination [34].

Institutional Responses to Discrimination

Students blame perpetrators for mistreatment arising from discrimination and themselves for not resisting it. Discrimination can be subtle and manifest in casual remarks in day-to-day encounters. Individual medical student may perceive such experiences and respond to them in different ways. This may detract from organisational responsibility for dealing with discrimination. The dynamic relationship between individuals and institutions is central to medical culture and combating mistreatment [22].

Definitive institutional responses include policies to deal with discrimination, clear channels for student to confidentially report experiences [36] and providing support to students. Specific, trained staff should comprehensively investigate complaints of discrimination [36]. Proactive approaches have been suggested such as education to promote diversity and training in equality [25] and formally training senior staff to teach junior colleagues [44]. Educational workshops may impart skills in how to respond collegially and assertively to harassment and mistreatment [45]. This may lead to conversations about whether such training should be mandatory and reinforced on a regular basis [27].

Providing a safe forum to discuss dilemmas [22] may enable reflection on the dynamics of teams [14]. In this context, students can be encouraged to notice behaviours that devalue, ridicule or detract from the dignity of persons and made aware about the implications of ignoring and normalising them [27]. Teachers and supervisors are influential in modelling critical reflection on structural and cultural determinants that influence health access and outcomes [9, 14].

Directions for Future Research

Medical students experience discriminatory treatment based on gender, ethnicity and mental illness. Empirical data collected from students who experience discrimination on the basis of their religion, age or sexuality was limited [9]. Discrimination was commonly subsumed into adverse experiences such as harassment, abuse and bullying and evaluated as a separate entity.

There are challenges in researching discrimination: Firstly, the idea that discrimination can be dismissed as perception; secondly, the difficulty in gauging the subtle, indirect nature of discrimination; thirdly, identifying specific interventions to increase awareness of discriminatory attitudes and treatment that members of faculty would support. Academic teaching staff and clinical supervisors need to be actively involved in promoting diversity and inclusion [9] to shift attitudes within institutions.

Future research might include (i) a validated instrument to collect more detailed longitudinal data on student characteristics and specific discriminatory experiences; (ii) evaluating the process of reporting experiences of discrimination and identifying specific barriers to reporting; (iii) targeted educational interventions based on real clinical scenarios that enable students and teachers to identify prejudicial attitudes, bias (both conscious and unconscious) and discriminatory practices; and (iv) evaluating institutional policies on discrimination and exposing discriminatory practices.

Limitations

A narrative review approach was employed to integrate themes across studies such as the contextual background to types of discrimination. The potential for selection bias is acknowledged despite inclusion of a diverse, international range of studies. The use of heterogenous international cross-sectional surveys with different methodologies limits comparison by quantification and interpretation of the varied cultural settings that influence discriminatory treatment and reporting.

Conclusion

Discrimination is widely experienced and underreported by medical students, who are not empowered to challenge supervisors and senior staff. More research is needed to evaluate how institutions address discrimination experienced by medical students in clinical settings. Future research might focus on longitudinal data collection, factors that influence reporting of discrimination, interventions to raise awareness of discrimination and evaluation of policies that expose discriminatory practices.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

NA