Revisiting the Exhibits—Medical Student Reflections on Changes to the Institutional Portraiture at a US Medical School

Abstract

Background

Yale School of Medicine’s (YSM) Sterling Hall of Medicine (SHM) has historically been lined with large oil paintings of mostly White men, despite over a century of Black and female enrollment. These spaces can be seen as exclusionary to students underrepresented in medicine, and may result in decreased well-being and adversely affect academic performance. Student-led activism has resulted in recent changes to these walls, including the addition of images of women faculty, and artwork by students, faculty, and staff.

Objective

We aimed to evaluate how recent changes to longstanding historical portraiture in SHM affected students’ reflections on being in that space.

Design

This was a qualitative study based on semi-structured interviews conducted virtually.

Participants

Second- to fourth-year YSM medical students were interviewed.

Approach

Qualitative interviews were used to gauge students’ impressions of how they perceived both the original and updated artwork and portraiture, as well as the overall physical environment.

Key Results

Nine interviews were conducted, with interviewees describing the portraiture as reflective of YSM’s institutional values. They related this to other aspects of an exclusionary environment, and noted that they created belonging at YSM within smaller communities. Students recognized and expressed appreciation for the changes to the portraiture, particularly the increase in diverse representation, and they noted stark contrasts to the prior space. While they describe positive attitudes regarding changes in SHM’s exhibited portraiture and art, they also expressed skepticism about whether these changes were performative or whether they reflected true commitment to reform.

Conclusions

This study depicts how the portraiture and physical environment of a medical school affects medical students, and that interventions to reform institutional portraiture can have considerable impact on students’ attitudes regarding their medical school experiences.

BACKGROUND

The Yale School of Medicine’s (YSM) Sterling Hall of Medicine (SHM) serves as the visual touchstone of the institution. Historically, its halls have featured large oil paintings of White men. For almost a century, these institutional portraits of White men were among the most prominent visual adornments at YSM.

As Caroline Knowles explains, space is “an active archive of the social processes and social relationships composing racial orders…it interacts with people and their activities as an ongoing set of possibilities in which race is fabricated.”¹ As described by Elijah Anderson, the most distinctive feature of a “White space” is the “overwhelming presence of White people and their absence of Black people.”² By this criteria, the institutional portraits of near-exclusively White men (and a few White women) marked YSM as a “White space,” a setting “in which Black people are typically absent, not expected, or marginalized when present.”² Other studies have noted that a lack of inclusivity in the medical school learning environment can have a negative impact on medical students’ educational experiences and well-being.^3–5 Previous studies have described how bias, discrimination, and mistreatment adversely affect medical student performance and increase burnout.^6,7 More recently, research has shown that experiences of so-called microaggressions are associated with increased self-reported depression symptoms and decreased academic engagement.^8,9 However, there is a paucity of research on how other unspoken aspects of medical school diversity climates impact medical students. Furthermore, although many academic medical centers are filled with similar portraits of mostly White men,¹⁰ there is little research on how such racially homogenous portraits affect medical students (particularly non-White medical students) who co-occupy the space.

Prior to the onset of COVID, nearly every medical student at Yale regularly passed through the lobby and second-floor hallway of SHM in order to attend classes, use the library, go to meetings, and attend special talks and lectures. In 2018, the portraits lining the walls of SHM consisted of 52 portraits of White men and 3 portraits of White women,¹¹ despite over a century of Black and female enrollment.

In 2018, we conducted a study that assessed Yale medical students’ reactions to this body of portraiture and its effect on their experience at YSM. In that study, we identified four major themes based on a qualitative analysis of student interviews. These themes included (1) students’ perceptions of the institutional portraits as a visual affirmation of YSM’s institutional values such as whiteness, maleness, and elitism; (2) students expressed resignation to the status quo of institutional portraiture that was dominated by images of White men and had developed coping mechanisms such as humor and avoidance in order to deal with the lack of diversity in the portraits; (3) students spoke about contemporary consequences of such homogenously White portraiture, such as underscoring the lack of a sense of belonging for minoritized students, or the feeling that having portraits of White men who may have endorsed slavery or opposed the admission of women to medical school implied YSM’s implicit endorsement of those positions; and (4) students spoke about the erasure of history from varied points of view—some students felt that removing the portraits would erase important aspects of YSM’s history, whereas other felt the portraits themselves constituted an erasure of the history of women and people of color at YSM.¹²

Student protests and efforts spearheaded by student-led committees led to the formation of the YSM Program for Art in Public Spaces (PAPS) in 2018^11,13,14. PAPS was tasked with “ensuring that the artwork in public areas at the school reflects our mission, history, and the diversity of our community.” As part of this mission, PAPS returned fifteen of the 55 total historical portraits from SHM to their departments of origin. In addition, PAPS organized a two-part exhibit of photographic portraits of women faculty, entitled “Aperture 1 and 2,” which opened in March and August 2019, respectively. Aperture 2 remains on display on the second floor of SHM. An exhibit titled, “Self-Reflection,” was displayed on the first floor of SHM from February 2020 until December 2021, and featured artwork created by YSM students, staff, and faculty, including several commissioned photographs depicting medical and graduate students from communities that are underrepresented in medicine (URM). PAPS also commissioned an oil painting of Beatrix Hamburg, MD, an internationally renowned psychiatrist and the first Black woman to graduate from YSM.

In this study, we interviewed medical students in 2020 regarding their responses to the institutional portraiture at SHM after these changes were implemented.

METHODOLOGY

This was a single-site, qualitative study using semi-structured interviews. The study was granted IRB approval by our institution.

Researchers and Study Participants

Researchers were men and women, and included NA, SMC, EF, CK, AR, and MM. Interviewers were SMC, CK, and MM who were second-year medical students. Participants were made aware via email that the study sought to assess the effects of institutional portraiture on medical students, and as such, participants were medical students at YSM in their second- to fourth-years, in optional research years, or completing combined degree programs (e.g., MD-PhD). As a result, some of the interviewers knew their interviewees prior to the study. First-year students were excluded, as they were considered to have not yet spent sufficient time in the physical environment of SHM at the time of the interviews. Interviewees were recruited via emails sent to class listservs (convenience sampling) and participants were able to independently encourage peers to participate (snowball sampling).¹⁵ There was no targeted recruitment of any particular demographic group.

Interviews

Confidential, de-identified interviews were conducted over Zoom (Zoom, Zoom Video Communications, Inc., San Jose, CA) between October and November 2020 by MM, SMC, and CK. Each interview lasted for about 30 min. Interviewees were consented to Zoom interviews being recorded, transcribed, and de-identified at the beginning of each interview. Only interviewers and interviewees were present during interviews. Interview questions were developed through collaborative brainstorming between researchers, with adaptation from relevant themes identified via literature review and the interview guide from our 2018 study.^12,16 The interview questions were not pilot-tested, and interviewees did not receive the questions in advance. The interview guide contained bolded questions asked to every interviewee, and non-bolded questions which were optional, depending on the direction of a particular interview. Interviewees were provided with a demographics survey following each interview, where they selected from provided options for race (as many as apply) and gender (for which options beyond male and female were also included), with the additional option of self-identification for both. All interviewees completed their interviews; no participants dropped out during the study. There were no repeat interviews performed. Interviewees did not review their transcribed interviews or comment on the findings.

Data Charting and Analysis

Interviews were transcribed using Otter, an artificial intelligence transcription tool (Otter.ai, Los Altos, CA). Thematic analysis was used to identify major themes obtained through the interviews.^17–19 Interviews were cross-coded using NVivo (QSR International, Burlington, MA), and inductive analysis based on these codes was performed by EF, MM, SMC, and CK. Thematic saturation was reached after 9 interviews, when coding revealed stability in emerging themes.¹⁷ Qualitative analysis was conducted using NVivo software (QSR International, Melbourne, Australia).

RESULTS

Table 1 provides demographic information obtained for interviewees from the interview cohort, with major themes described below.

Table 1.

Demographic Data

Self-reported demographics
Gender
Male	3
Female	6
Race or ethnicity
African-American	3
East Asian	4
South Asian	0
Hispanic	1
White	2

Theme 1: Art as a Representation of Institutional Values

Students described the original historical portraiture (prior to the PAPS interventions) as representative of YSM’s exclusionary institutional values, such as whiteness, maleness, and elitism, with relevant quotes provided below and in Table 2. While they described these values as expected from institutions such as YSM, they felt such values did not reflect the current makeup of the school, or adequately reflect current progressive advocacy.

Table 2.

Quotes with Representative Themes

Institutional values	“When I first came to Yale. I was like, this seems cool. It seems like what you’d expect from an Ivy League place, like a bunch of old paintings with ornate frames on them…and the fact that a lot of people seem like, I don’t know what era they’re from, but their clothing was like, late 1800s, early 1900s. So it’s kind of like, showing the longevity of the research. Like they were doing research here for like, over 100 years in this building, which I thought was cool.”—Interviewee 1 “I feel like the old ones are probably more representative of what YSM actually is. So like, old white men commanding everything, which I feel is like, still true.”—Interviewee 9 “And so you know, I think art is like a, you know, a reflection of the culture and the society that creates it. … For example, if it was just always like, the old leaders of the med school, that’s one form of artists remembering history, but I think another part is like reflecting where you want to go and what you want to represent…because if you don’t see it, you don’t talk about it, then the structures aren’t going to change...”—Interviewee 2 “I mean, it’s definitely unwelcoming. … Asians aren’t really like underrepresented in medicine itself. But I think they’re very underrepresented in leadership in medicine, like, rarely do you see them as like Deans or like heads of departments. …it just doesn’t mirror like, what the actual population of physicians is. Same for like other people of color, but you know, seeing who Yale decides to honor with a portrait just I guess, just reminds me of the fact that it’s harder for me like a woman and also like, an East Asian…”—Interviewee 4
Performativity and skepticism	“…I think, you know, it seems to be a cyclical thing, because, …these demands, [are] basically the same as what we asked for five years ago, and five years before that, and things like that. And it’s funny how that is… roughly the average length of a medical student at Yale. …And then enough old students have graduated that the new students can really like talk about it, and then all of a sudden, you know, who knows what happens? Administration says something XYZ, there’s like almost a placation. And then like, you have to wait five more years for those students to graduate before you get almost a new energy.”—Interviewee 2 “Yale is actually a lot more backwards than I realized. I just remember coming into medical school, like I thought this was the perfect place to be, and I still think it is, but I’ve noticed that, you know, there are still a lot of problematic issues going on at Yale…and the one other thing that I realized is that some departments, when we went to Grand Rounds, I would walk in and everyone would pretty much be white… So walking into that space, like, there’s only one other Asian faculty member, and no one is Black, and there’s just like a lot of whiteness… But yeah, as an institution, like Yale likes to think it’s progressive, but there are still so many things among the faculty that is still very backwards. So that’s something that I’ve come to learn the hard way.”—Interviewee 3 “I think they want to be progressive. I think sometimes they want to try and do the things that we would ask for. … Sometimes it feels like they’ll do these things, or they say they want to do these things. But then, like, no change really happens, I guess.”—Interviewee 4 “And then I think recently with the demands, I think they always want to talk to us about these things, but they never want to follow through with any of the actions even when we give them like actionable items that we would like want them to pursue.”—Interviewee 4 “…I think there was another study like this done previously by a student where like, it ended up getting these amazing portraits on the walls, which I think was a valiant effort but it’s really it feels on YSM’s part performative in nature to let them commission new portraits and hang on the walls while nothing else changes about the school.”—Interviewee 9
Created belonging	“…But I think my sense of belonging comes from the friends that I’ve made and the communities that I formed…I think it would be great if those reflections were also in the administration because I think that then that sense of belonging would expand to the school itself.”—Interviewee 2 “Yeah, I think that I do [belong] based on our current medical system, like I don’t think that I like had a right to go here or anything, like I’m very lucky to have been accepted and to go here. It’s kind of not like talked about much but like Yale Med, kind of has a reputation of being very Asian. Like when you look at our composite there are like rows of like Asians like the row that I’m in…yeah, so I feel like there are a lot of people I could like identify based on my like demographics background here. Although that’s not necessarily like true of faculty, like the current medical student demographics are different from faculty.”—Interviewee 6 “I think that over time, I’ve kind of found I found a good group of friends and good group of people who helped make sure that I feel like I belonged, I would say, um, and like, I think I’ve had the opportunity to meet a lot of really kind mentors and people like that who have like, honestly, just really made this a more like welcoming space for me.”—Interviewee 8
Students’ reception to change	“Yeah, there was one time when they had like…there were some portraits near I think it was near the dean’s office. And there were some portraits of like, different women. I think it was the women in medicine series. I really like that, that was very positive for me. And also like, the displays when you walk into the library, and you’re going towards 115. And like, they’ll just change the different displays. I really like what they’re doing, especially the one that they have for disability.”—Interviewee 5 “When you walk down there, that’s where all the new portraits of women are. And it’s a pretty stark contrast, because they’re all women. And then they’re all photographs instead of them being portraits, like paintings. So you can tell that they’re much more modern.”—Interviewee 6 “…So I guess that’s also saying something because I remember first hearing about them wanting to change the portraiture in the library, and me just being like, oh, there were portraits there? Because that, just like, goes to show how much I started to tune that out.”—Interviewee 7 “…Like portraits… there’s like this sort of air of prestige to them and like, you feel like you have to be established to some respected old family or like wealthy, but I think modernizing it a bit and showing students is like, you know, showing us that yes, we do care about like what we look like now and not what we looked like in the past, so I really like seeing that and actually know one of the people who has the portrait there and I was like, oh this is really nice.”—Interviewee 7 “And the new portraits. I feel I see more people who look like me on there. …It’s like seeing a visual celebration of our efforts is like nice.”—Interviewee 9

“…we went to the History Museum where we saw that picture of the old white man with the slave and they finally revealed to us that like, he’s actually the founder of Yale, right … I felt very detached and this person obviously, wouldn’t have been happy with me being in this place that he founded, or like being anywhere near it, that wasn’t in a position that was like, custodial. So I felt the same about those portraits on the wall before the change because like, even if the people who put those up didn’t mean to, they like reminded me of the founding of Yale and the old white men who founded it and the long march to have like any type of integration.” —Interviewee 9

“Art is a reflection of the culture and the society that creates it. So, you need to make it a conscious reflection. So, if you don’t represent where we want to be or where we want to go, or use art as a statement piece and make comments on society, then for example, if it was just the old leaders of the med school, that’s one portrait, one form of artists remembering history.” —Interviewee 2

Theme 2: Performativity and Skepticism

Several students commented that the administration seemed more interested in the appearance of progressivism rather than in enacting racial and gender equity-minded reform. Even though students voiced appreciation of the changes made since 2018, they expressed skepticism about whether these changes were part of systemic institutional reform or isolated performative gestures.

“It feels on YSM’s part performative in nature to…commission new portraits and hang on the walls while nothing else changes about the school.” (Interviewee 9)

“I think YSM does a good job of keeping people appeased in two ways, right? The people who don’t actually want them to become a more inclusive and diverse place, they appease by really doing nothing. The people who actually—the minorities and their allies, the URMs here and their allies who actually want change here—they’re not satisfied with the way YSM is, right. But they appease them, or if not appease, keep them at a level where they’re not going to like publicize all of YSM’s failings by showing them the task forces, promising them things that will never actually occur, and not giving them the knowledge that they actually need.” —Interviewee 9

Theme 3: Created Belonging

In response to the “unwelcoming” (Interviewee 3) environment created by the historical portraits, students described “created belonging” built with classmates within smaller communities. One first-generation college student remarked, “I sort of found my people and created my sense of belonging [in college], and I think it was the same way at YSM.” —Interviewee 2.

“I think my sense of belonging comes from like the friends that I’ve made and the communities that I formed because it’s within those people that I that I see myself... I think it would be great if those reflections were also in the administration because I think that then that sense of belonging would expand to the school itself. But for me, I don’t I don’t think of my belonging as tied to like the institution.” —Interviewee 2

“Everyone gets imposter syndrome sometimes... I think that I have made very, very good friends here with whom I share a lot of common interests in general values that I haven’t made anywhere else. So, I think that in that respect, yes, I do feel like I belong here.” —Interviewee 7

Theme 4: Students’ Reception to Change

When asked about their awareness of any recent changes to the institutional portraiture, all students expressed that they were cognizant of these changes, such as the 2019 Aperture exhibit highlighting underrepresented members of the YSM faculty. They viewed these changes in a generally positive light.

“I think they’re, like very positive. Because usually, like with the new portraits, we’ll have a description. And sometimes they’re also like, people that you know, or recognized, or people who have like, taught our lectures… which I think makes it a lot more interesting.” —Interviewee 6

“I didn’t know that they had been trying to get those portraits changed. So, I think when I noticed that it was a sense of like, oh, good, they actually listened and they actually did what the students wanted them to do, which was a bit of a relief because we all know that sometimes that doesn’t happen.” —Interviewee 7

Students also reflected on changes they hoped to see in the future.

“I think progress is being made and like, like changes for the interior the buildings and like, in terms of what we choose to represent there. And I think I would continue with that trend and spread that out across the medical school” —Interviewee 2

“I would have liked to see more representation from other races and like more diversity in those portraits, because it would have at least made me feel like Yale is respectful and recognizes these people’s achievements as well.” —Interviewee 3

DISCUSSION

Prior scholarship has posited that public artwork and memorials function to signal the official values of nations, communities, and institutions.^20,21 Social geographers in the USA have described the capacity for built environments to alienate minority groups, particularly Black people.²⁰ Portraiture has been used by professions to delineate insiders and outsiders, as well as represent values and power structures, including hierarchies of race, gender, and class.²² In medicine, portraiture has been used to model the ideal physician and allow the physician-viewer the opportunity to see themselves in the idealized subject, which, for much of American history, has been a White, male subject.²³ Our study is an important step in understanding contemporary medical students’ attitudes towards institutional portraiture.

Our findings show that medical students at YSM construe institutional portraiture as reflective of the institution’s values, particularly with regard to racial and gender inclusion. In an environment where the subjects of YSM institutional portraiture were mostly White and male, students described YSM’s institutional values as whiteness, elitism, maleness, and power. In toto, students experienced SHM as a racialized space and experienced the institutional portraits as part of active racialization. It is notable how this theme was present in our 2018 study and again re-emerged in this one.¹² This consistency underlines the importance of institutional portraiture as a vehicle for communicating the institution’s values and priorities to medical students. Therefore, this finding challenges the idea of institutional portraiture as an ornamentation or visual archive and instead recasts it as a dynamic embodiment of the institution’s core values.

Previous ethnographies have explored how minoritized individuals interact with racialized landscapes, finding that some of these individuals will go out of their way to avoid spaces that produce “a message of racial hierarchy.”^20,24 This was reflected in our 2018 study, where interviewees expressed an attitude of resignation and avoidance regarding academic visual culture, as portraits of White men seemed to be the status quo at similar institutions.¹² This feeling appeared related to a sense of powerlessness to effect change, and thus involved the use of coping mechanisms to exist within this status quo. In this later study, students embodied a more empowered attitude, which appeared directly related to YSM’s initiatives to diversify its institutional portraiture. Students appreciated seeing themselves represented on the walls in the more recent exhibits, in stark contrast to feeling excluded by the prior portraiture. Both male and female interviewees were struck by seeing images of women on the walls. The positive responses to the PAPS interventions, even from those who expressed being minimally impacted by the previous portraits, show that changes in institutional portraiture and visual culture are appreciated by students and are therefore a worthwhile endeavor for medical schools to take on.

However, while they were appreciative of recent improvements in the diversity of institutional portraiture and artwork, interviewees voiced skepticism about the institution’s motivation for enacting such changes. Students’ appreciation of the changes to the physical environment was tempered by institutional distrust, which manifested in concerns that these changes in portraiture might be performative, sidestepping deeper and more meaningful structural reform. Some examples of what YSM interviewees considered meaningful reform included fostering a more diverse student body and faculty, implementing anti-racism in the medical school curriculum and hospital system, and committing more strongly to investment back into the city of New Haven. Students recognized that increasing the inclusivity of institutional portraiture and art is just one of many steps towards dismantling White supremacist culture and racist, exclusionary institutional practices.²⁵

Students described how the paucity of diverse representation, both among current faculty and in the portraiture, affected their sense of belonging. Peers, faculty, and physical space can each influence this sense of belonging, which has been shown to directly affect well-being and academic success, particularly among non-White students.^26–28 Our interviews showed that institutional portraiture depicting mostly White men created an “unwelcoming” environment for minoritized medical students at YSM, which led them to seek a sense of belonging within informal communities that they formed themselves. This need for “created belonging” that some students noted has also been described among minority groups at other medical schools and reflects one of the additional burdens faced by URM medical students.⁴ Elements such as institutional portraits that create unwelcoming learning environments can be significant contributors to stress for URM medical students, which may negatively impact performance, hinder the recruitment of future URM students into these programs, and ultimately result in a lack of diversity among future physicians and medical school faculty. As medical schools seek reform, it is critical to recognize that reforms must extend beyond curriculum and faculty reform, and also address the physical space itself.³

It is worth noting that the changes at YSM have also been part of a larger national movement to remove symbols and images commemorating racist and oppressive histories, such as mass gatherings during the 2020 Black Lives Matter protests that targeted statues with racist undertones and implications^29,30 Along these lines, the Mellon Foundation has pledged $250 million to support continued efforts towards the restructuring of the country’s memorial landscape.³¹ Many academic institutions, including medical schools, are currently grappling with their institutional portraiture as well, and our study shows that such efforts will likely yield real benefits for medical students, particularly those from communities that have been historically excluded within medicine^10,32–35

LIMITATIONS

The limitations of this study center around our interviewees being solicited through convenience and snowball sampling. This led to a self-selected cohort of student-interviewees which included a few White men. We attempted to mitigate this through neutral recruitment language and an explicit call for all opinions in our email requests for interviewees. Our interviews ended as planned when we reached thematic saturation, but had more interviews been conducted, it is possible that additional themes may have emerged. Additionally, we limited our interviews to students; further research should explore the viewpoints of faculty and staff, who typically have much longer durations at their institutions than students, and thus, might provide more longitudinal and varied perspectives.

CONCLUSIONS

This study provides novel insight on how changes to institutional portraiture at a medical school have tangible effects on medical students and their sense of belonging. Despite concern that changes to institutional portraiture might be performative, students expressed hope that these changes might be steps towards greater inclusion of a diverse, anti-racist student body and faculty, and a signal that their identities are valuable and worthy of honor and memorial at YSM. Internal interventions to reform institutional portraiture had a positive impact on Yale medical students’ experiences of and attitudes towards their school. To move forward, academic institutions must reject complacency and continuously re-examine the physical spaces in which learning takes place. Our findings suggest that rethinking and reforming institutional portraiture should be a priority for medical school administrators as they strive to create more inclusive educational experiences for diverse medical students.