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June 23, 2022

The 'death spiral' forcing Black physicians out of their residency programs

Daily Briefing

    Black medical residents are leaving or being terminated from training programs at substantially higher rates than white residents—a problem that has persisted despite efforts from medical schools and other organizations to increase diversity in their programs, Usha Lee McFarling writes for STAT News.

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    'It was stolen from me'

    Despite excellent academic backgrounds and research credentials, many Black residents report difficult and dismissive experiences during their residency programs, often facing "higher scrutiny, overpolicing, and more negative reports," McFarling writes. Many are then placed on probation before being quietly dismissed from their programs.

    "That is the playbook," said Owoicho Adogwa, an assistant professor of clinical neurosurgery at the University of Cincinnati and a cofounder of the American Society of Black Neurosurgeons. He also calls the development a "death spiral" for many Black residents.

    For example, Rosandra Daywalker, a former resident at the University of Texas Medical Branch (UTMB), had initially done well in her residency under a supportive female program director, but after the director left, she "[s]uddenly … could do no right," McFarling writes. From then on, Daywalker said she was routinely denied rotations, intimidated in the operating room, accused of posing safety issues, and faced hostile comments about Black and Hispanic patients from faculty members.

    "I saw my wife go from being a super confident, growing superstar — in terms of medicine, she's 10 times better than me — to just getting by, waking up anxious and depressed. It was really hard to watch," said Marcqwon, Daywalker's husband and a family medicine attending physician at a health center near Houston.

    After more than three years, Daywalker left the residency program in 2018. Although she was not fired, the Texas Workforce Commission determined she was "constructively discharged," meaning her working conditions were so untenable that her only option was to leave. 

    "What's painful is I wasn't allowed to make that choice for myself," Daywalker said. "It was stolen from me."

    In 2020, Daywalker filed a lawsuit against UTMB for how she was treated during her time in its residency program. By speaking publicly about her story, Daywalker said she hopes to help protect future residents. "I know too well the dangers of a toxic workplace," she said.

    A trend of racial bias against Black residents

    In 2006, a small study suggested that the high rates of attrition among Black residents was an "open secret" even back then, McFarling writes.

    Of the 19 Black residents interviewed for the study, 13 reported seeing or experiencing unfair treatment, including termination. Overall, Black residents believed "they had fewer chances to make mistakes than their white counterparts," leading many to doubt themselves and be "on guard at all times," the study authors wrote.

    Since then, "[l]ittle, it seems, has changed," McFarling writes.

    According to an unpublished analysis from the Accreditation Council for Graduate Medical Education, Black physicians made up around 5% of all medical residents but represented almost 20% of the residents who were dismissed from their programs in 2015. And in the elite, lucrative, largely white specialties, "the numbers may be even bleaker," McFarling writes.

    In addition, a 2020 survey of 7,000 medical residents found that almost 25% had experienced discrimination because of their race, ethnicity, or religion, with the highest rates among Black residents. This discrimination was also associated with higher rates of burnout and not finishing residency.

    "When you have such a high attrition, it raises the question, is something wrong with the applicants? Is something wrong with the screening?" Adogwa said. "Or is something wrong with the system?"

    Although efforts have been made to increase the number of Black students in medical school, there has been little focus on retaining Black physicians during their residency, a time when their advancement may rely on "subjective evaluations that can be tinged with bias," McFarling writes.

    For example, a study published in Academic Medicine found that internal medicine residents from underrepresented groups received lower ratings than white residents on five of six core competencies. The largest differences came from the domain of "professionalism," which the authors called a "hidden curriculum."

    "The standards reflect the people that teach — mostly white men — and the notion of what they hold as professionalism can trickle down insidiously," said Robin Klein, an associate professor of medicine at Emory University and the study's lead author. "It opens up the door to enable bias."

    In addition, Sherri-Ann Burnett-Bowie, an assistant professor of medicine at Harvard Medical School and one of the study's authors, said that differences in residents' ratings, even if they're small, "really do have consequences for someone's professional trajectory" and can erode confidence over time.

    "You hear, year after year, stories of people having their dreams wrenched away not because they were reckless, not because they couldn't be part of a team or were technically incompetent, but because they didn't have an environment that leveled the playing field," Adogwa said. "What happens in residency is the same thing that happens in society: You have the same rules applying differently to different people because of the color of the skin." (McFarling, STAT News, 6/20)

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