For Women of Color in Medicine, the Challenges Extend Beyond Education
The complexities of applying, a lack of mentorship, and struggles to navigate the system are just a few of the roadblocks
Women physicians face constant reminders that they are women in a field created by males, that no matter what they say or how they dress, that they will be mistaken to be everyone except for the physician. Being a person of color in medicine comes with its own issues — from lack of mentorship and guidance to the complexities of applying to medical school and navigating the bureaucracies. “It’s a double-bind,” says Uche Blackstock, M.D., an emergency medicine physician and CEO of Advancing Health Equity, of the dual burden women of color physicians carry.
There are negative stereotypes at work, where the few women of color who are in academic positions in medicine feel that, if they speak up, they are often seen as aggressive, and if they do not, as not being assertive enough. Further, women are faced with bullying, overt sexism, and institutional roadblocks. Additionally, underrepresented minority women physician scientists oftentimes are isolated due to lack of diversity, discrimination from patient families, bias from colleagues and superiors, and tokenism.
The difficulties women of color face start long before medical school. The simple act of applying to medical school is confusing and filled with nuances. Because medical school applications are extremely selective, with institutional acceptance rates ranging from 3% to 12%, the pressure to conform to become the most attractive applicant is high. What makes up the most attractive applicant is oftentimes divulged through social groups as a form of social currency. For many women of color, there is an inherent lack of clarity on what that means.
Health profession advisors are not evenly spread out throughout higher education institutions, where under-resourced institutions are less likely to provide financial and institutional support for their premedical students. While second-year student Courtney Chineme was a pre-medical student in college, she also says she did not know the ins and outs of the medical school application. She took multiple gap years to become a good applicant and saved up for medical school applications, which can cost $2,800 in application fees alone, not accounting for travel and accommodation costs for interviews.
Because medical school applications are extremely selective, with institutional acceptance rates ranging from 3% to 12%, the pressure to conform to become the most attractive applicant is high.
It does not end there: Writing the application essays, where each phrase and sentence is labored over, is stressful. Courtney remembers writing her personal statement about how she wanted to give back to the Black community by trying to correct health disparities and inequalities that affect the community. However, her mentor, a White woman, suggested that she consider avoiding such a “controversial” topic. While Courtney decided to ignore her mentor’s advice and write about her true interests and is currently attending medical school, similar questions and decisions are labored over by many others so that they can have an appealing application.
Whether or not Courtney’s mentor was well-meaning or not, the idea of being as agreeable as possible is not new. There are a plethora of reasons for not gaining an acceptance to medical school and many applicants find conformation easier when there is so much riding on the line. Natalie Doe, a current student at Ohio State’s MedPath program, remembers spending time researching Black hair styles that would be acceptable for medical school interviews and coming across an entire forum dedicated to the topic. Some of her friends went out and bought wigs instead of wearing their hair naturally. Kristyn Smith, an emergency medicine resident, echoes the same thing.
It’s not only their appearances that get examined, however; it is also sometimes getting asked a question that seems charged with bias. Doe recalls an interview where she was asked to comment about the government, something she was reluctant to do in today’s volatile environment, where many people of color feel unsafe. Amira Saad*, a second-year medical student who’s Muslim and wears a hijab, recalls a medical school interview where she was asked if she was going to get married and have children.
The pressure to conform to try and avoid overt racism and sexism continues, whether in medical school or further into their careers. Many women of color, especially Black women, feel unsupported in their classes in medical school. Some of Amira’s Muslim friends stopped wearing their hijabs once they started working in a clinical setting, in fear of explicit and implicit bias from patients and attendings, appearing as women of color and more foreign despite the fact that they grew up in the United States. For Asian-American women, there are also concerns about appearing too young to have the proper credentials as well as concerns about nativist attitudes from patients. Many women try to counteract these concerns by dressing a certain way but, sometimes, it is not enough.
Further, women of color trainees often look to their superiors for validation regarding their concerns. As a resident, Kristyn remembers doing a cultural competency presentation about practical ways physicians can treat people of color and feeling reassurance that she was presenting after a White female attending physician who presented on the historical basis of structural racism in medicine as the physician was a superior and thus, giving her confidence and a form of acknowledgement, that it was a real problem in medicine.
Medical trainees are an especially vulnerable population due to the amount of stress that they face during training, especially female physicians, who are 1.6 times more likely than their male colleagues to commit suicide. Despite fears of retribution, Dr. Blackstock offers an alternate way to bring up concerns and finding allies in leadership who can help frame requests or concerns in a more palatable way to administration. If it is something that means a lot to trainees, then trainees should find mentors and allies, she says, who, despite perhaps not looking alike, are like minded and supportive, and maybe even who are not at the same institutions as the trainee. Further, she advises that a mentor/mentee relationship is an active role for both parties — mentees should do the majority of the work and meet regularly to talk about their concerns and questions that they have prepared.
It does not get better once the already small population of women of color trainees reach positions within academic medicine. Women of color make up just 3.2% of full professor positions in the field. Women who are non-White and clinical faculty members leave full-time appointments at higher rates than White men who are basic science faculty. Many cite issues of discrimination, institutional roadblocks, bias, lack of mentorship and more as reasons for leaving. Further, women of color are disproportionately selected to sit on diversity focus groups and committees, which takes time away from their scholarly pursuits, which are necessary to advance in academia.
It is not uncommon for women of color to be placed in positions of power in academic medicine, only to ultimately leave the field due to the extensive institutional barriers they encounter when they try to change the culture of medicine.
This “minority” tax can lead to burnout and additional frustrations, further exacerbating the lack of women of color in academic positions. Dr. Blackstock also says that there is an added burden for women of color who are in a jeopardy situation — speaking up means risking the negative stereotype of being an aggressive minority, while not speaking up can lead to people assuming that they are not assertive enough.
Many academic medical centers hold seminars about how women, especially women of color, can work on their soft skills, such as CV writing and speaking up. But Dr. Blackstock, like many academics in medicine, believe that there needs to be a top-down type of acknowledgement about the deeply rooted issues that women, especially women of color face instead of working from the bottom up and placing the onus of change on women of color, who are often placed in unsupported positions. It is not uncommon for women of color to be placed in positions of power in academic medicine, only to ultimately leave the field due to the extensive institutional barriers they encounter when they try to change the culture of medicine. It makes it more difficult for women of color in academia, where they make up only 28% of the women faculty at academic centers. The statistics are even more daunting at the higher levels, where women of color only make up 3% of academic department chairs.
At each step of the way in academic medicine, women of color increasingly make up fewer and fewer of the positions. When women of color faculty leave, trainees lose possible mentors which can be detrimental to the advancement of their careers. There is also a pervasive narrative for women of color in medicine: that they need to develop resilience towards the various roadblocks they face throughout their careers and build character. Due to this, if they exit, then it’s assumed that they do not have resilience.
Further, increasing the diversity of medical school populations is not enough to tackle systemic issues of racism and sexism. Women of color are equally liable to succumb to bias as their White male and female peers. Medicine is learned through apprenticeship — trainees pick up the nuances to the humanistic aspects of talking to patients, treating them, listening to them and more through the actions of their superiors. There cannot be a bottom-up approach to issues that women of color face if there is no institutional recognition and active solutions to try to solve the issues.
However, there are also positive signs that medicine is starting to make changes. Times Up Healthcare, an offshoot of the larger Times Up movement, is campaigning to fight gender as well as racial inequality in medicine. There are increased pipeline programs that target underrepresented minorities to increase numbers, such as the program at the University of Illinois at Chicago Urban Health Program that supports access and preparation for health careers starting from elementary school until undergraduate years. Discussions about the effect that structural racism plays on medical school admissions and healthcare at large also help to start the conversation, which is the first step.