An Extra Burden of Bias for Minority Resident Physicians

Aba Osseo-Asare, MD

A qualitative study of minority resident physicians’ experiences related to race/ethnicity highlighted the particular discrimination and demands that black, Hispanic, and Native American physicians experience during residency.

The 3 primary themes drawn from these in-depth interviews were the daily burden of microaggressions and bias, the role minority residents were asked to play as representatives of their race/ethnicity, and the hurdles of negotiating personal and professional identities while feeling a sense of “otherness.”

Investigators led by Aba Osseo-Asare, MD, Department of Internal Medicine, Yale School of Medicine, conducted semi-structured interviews with 27 residents from 21 residency programs across the US. Among the participants were 19 (70%) black, 3 (11%) Hispanic, 1 (4%) Native American, and 4 (15%) mixed race/ethnicity residents.

“We felt like there was a paucity of data related to the experience of resident physicians,” said Osseo-Asare on the impetus for the study. “There’s data for medical students and some at the faculty level, but not much about residency.”

Residency is known to be an especially challenging period in a physician’s training, but Osseo-Asare told MD Magazine® that “despite residency being a taxing time for all residents, our study showed that residency is a critical time for minority residents in particular.”

Interviews that Osseo-Asare and colleagues conducted with residents were transcribed and coded according to themes that arose. These included the 3 primary themes as well as numerous subthemes including “explicit bias,” “pressure to assimilate,” and “race/ethnicity ambassador.”

Participants shared of patients assuming they were nurses or transport, being surprised at the resident’s level of education, and asking them to perform tasks like filling coffee. However, the microaggressions were not limited to patients, but extended to fellow residents, attendings, and even program directors.

One resident recalled an early experience with such bias: “There was a senior resident that spent a whole week trying to figure out what my identity and ethnicity was just by looking at my hair. One day, it was like, ‘Are you mixed with Italian? Are you mixed with Mexican?’ And then, by Friday, he actually went and grabbed my hair.”

Osseo-Asare shared about an African-American resident who was told that he was “speaking street” when he use the word “cool” in a presentation. Other black residents told the investigators that they were often confused for the other black residents in the program, even though there were just a handful of them.

While many of the recounted stories concerned microaggressions, residents also described receiving explicit bias from patients. One Hispanic resident recalled an encounter with patient who delivered a xenophobic tirade: “…someone like you should go back to where you came from. You’re taking advantage of our resources, and there’s all these students that would like to get into medical school that are here and from the US and don’t get in. And then you people come, and you take our places, and you take our jobs. And you don’t even have citizenship, and you don’t even speak English.”

Despite repeated recollections of bias and microaggressions, residents shared a reluctance to report such incidents. In some cases this was because the perpetrators were other residents or faculty; others shared a belief that reporting incidents would make no difference or would cast them as “playing the race/ethnicity card.”

Another major theme of the interviews was the added role that minority resident physicians were asked to play in being ambassadors for their race/ethnicity, taking on additional care for minority patients, and organizing diversity programs.

“One of the most surprising elements was the extent to which programs were using residents as a proxy for a diversity program,” said Osseo-Asare. “That level of expectation and burden on residents, to take on diversity programing in addition to other responsibilities, was quite striking.”

Even when minority residents were willing to organize diversity and inclusion events or plan trainings, there were residents who said that their institutions did not provide adequate resources for the programming. One shared that no lunch was provided and that there weren’t enough chairs in the room for a session on diversity and inclusion.

The study authors list example after example of microaggressions, explicit bias, and unfair expectations. They indicated that this study is meant to generate hypotheses for future research. Osseo-Asare shared that one remaining gap is the extent to which racial/ethnic bias and other factors discussed in the study contribute to minority residents dropping out of residency.

“We are losing people of color as they advance through the stages of the medical profession,” she said. “Are those factors components of the gap we see in the minority pipeline?”

In addition to research, Osseo-Asare commented on the need for specific guidelines for residency programs regarding diversity and inclusion practices. She noted that when the study began in April 2017, there was no language in the Accreditation Council for Graduate Medical Education’s (ACGME) requirements for residency programs related to racial/ethnic diversity. Those requirements have now been updated to include some guidelines that will come into effect in 2019.

Beyond just residency programs, she highlighted the need for awareness and training for all providers and institutions.

“Efforts that help to make people more aware of the unconscious assumptions they make are the ones we should be investing in as a medical community,” said Osseo-Asare. “We all carry those assumptions.”

The study, “Minority Resident Physicians’ Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace,” was published in JAMA.