Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education—a Narrative Review

Abstract

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.

Association Between Racial and Ethnic Diversity in Medical Specialties and Residency Application Rates

“…Indeed, studies have reported a more substantial application-matriculation gap among URM trainees applying to surgical specialties than among Asian and White trainees. 3 , 44 , 45 …”

“…This suggests that Black medical students apply to multiple specialties, either out of greater uncertainty or concerns about successfully matriculating in their preferred specialty. Indeed, studies have reported a more substantial application-matriculation gap among URM trainees applying to surgical specialties than among Asian and White trainees …”

Racial and Ethnic Differences in Barriers Faced by Medical College Admission Test Examinees and Their Association With Medical School Application and Matriculation

“…There were 4 domains of variables hypothesized a priori as barriers (Table 1). The first is parental educational level, which we examined as a proxy for wealth . For this proxy, we used the AAMC variable of not having a parent with a bachelor’s degree .…”

“…As Nguemeni Tiako et al and others have written, this structural racism leads to several barriers for groups underrepresented in medicine, including differences in parental educational level and resources and differences in the networks and informal knowledge required to, among other things, secure clinical shadowing and other extracurricular educational opportunities valued in the medical school application process. Interpersonal discrimination creates yet another barrier whose influence can occur anywhere along the process . These barriers may help explain why groups underrepresented in medicine are more likely to declare in high school their intentions of becoming a physician than they are to apply to or matriculate at medical school .…”

Promoting Access to Medical School and Physician Workforce Diversity

“…Mounting evidence implicates structural racism as the foundational contributor to disparities in family wealth and educational opportunities that limit the resources needed for individuals to successfully apply and matriculate into medical school . Such factors upstream from the application and matriculation process must be addressed to advance parity in medical school access.…”