Female, Minority, Non-Heterosexual Medical Students Report More Discrimination, Mistreatment

Medical students with multiple identities considered historically marginalized are more likely to report mistreatment and discrimination during their time in medical school, according to a new US study.

The new findings from a team of Yale University investigators suggest students who identified as female, non-white, lesbian, gay or bisexual, or any combination of these, were significantly more likely to report recurring experiences of mistreatment and discrimination, as well as greater scores for exhaustion. The team expressed concern these factors contribute toward a disparate rate of burnout among the diverse populations of aspiring clinicians.

Led by Bethlehem G. Teshome, MPH, postgraduate associate and assessment, evaluation specialist at the Yale School of Public Health’s Department of Social and Behavioral Sciences, the investigators sought to describe the link between mistreatment, discrimination, burnout and multiple marginalized identities among US undergraduate medical school students.

Their cross-sectional survey and retrospective cohort assessment included 30,651 graduating students from 140 accredited US medical schools from 2016 and 2017. Participants had completed the annual Medical School Graduation Questionnaire—designed to evaluate medical school programs and experiences—at the time of their graduation.

Teshome and colleagues included sociodemographic variables in the assessment, included self-reported sex (male or female), sexual orientation, race, and ethnicity. Race or ethnicity were dichotomized as either White or non-White, with categories for the latter including Asian, Black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, Pacific Islander, multiracial, or other.

Specifically for sexual orientation, participants were dichotomized as either heterosexual or lesbian, gay or bisexual.

An intersectional analysis was used to examine the simultaneous effect of multiple marginalized identifies in 1 medical student, featuring the 8 unique identity combinations that were possible from the 3 sociodemographic variables of sex, sexual orientation, and race or ethnicity. “These unique identity groups provide a more granular and nuanced picture of the mistreatment, discrimination, and symptoms of burnout reported by students of varying identities,” investigators explained.

Mistreatment and discrimination metrics were assessed from several items of the graduation questionnaire regarding negative behaviors experiences by students. Burnout was assessed by the 16-item Oldenburg Burnout Inventory for Medical Students, featuring subscales for exhaustion.

Less than half (48.5%) of all respondents identified as female; 39.2% identified as non-White and 5.5% reported their sexual orientation as lesbian, gay or bisexual.

Overall, 46.0% of all surveyed students reported experiences of mistreatment. Another 9.5% reported recurrent experiences of multiple types of mistreatment. Male (59.1%) and heterosexual students (54.9%) were more likely to report no mistreatment experiences than female (48.5%; P <.001) and lesbian, gay or bisexual students (38.9%; P <.001).

Of the 299 students to identify as 3 marginalized identities (female, non-White, and lesbian, gay or bisexual), 88 reported recurrent experiences of mistreatment (P <.001). Another 92 reported multiple forms of discrimination (P <.001).

Such participants were the most proportionally affected students in the assessment. They were also more likely to report greater mean scores of exhaustion after graduating medical school, reported an adjusted mean difference of 1.96 (95% CI, 1.47 – 2.44) to male, White, heterosexual student scores.

Teshome and colleagues noted that previous research indeed showed female, non-White, and non-heterosexual medical students have experienced greater mistreatment and discrimination during undergraduate school. Their contribution to such analyses show such issues with national data.

Additionally, the new findings show a “significant association” between multiple marginalized identities and burnout among medical students.

“The higher exhaustion scores among historically marginalized students is consistent with prior non-intersectional studies that use the minority tax and racial battle fatigue frameworks to describe experiences among racial or ethnic minority medical trainees and faculty,” they wrote. “The additional pressure marginalized groups face to represent their communities or contribute to diversity efforts at their institutions and experiences of bias and discrimination likely contributes to the effect observed with this dimension of burnout.”

Investigators called for improved integration of support services, as well as student groups for marginalized identities, into both medical education and within each other. “Increased interaction between groups that focus on a singular aspect of identity could provide a support structure for students with multiple marginalized identities,” they wrote.

What’s more, continued efforts to bolster medical school faculty diversity should be pursued, as well as institutional support systems for groups adversely prone to worse exhaustion and disengagement scores such as lesbian, gay and bisexual students.

“Further, the fact that students with multiple marginalized identities reported greater exposure to recurrent mistreatment and discrimination indicates the need for leaders in academic medicine to improve the existing mechanisms for dealing with reports of negative behaviors and create a climate of respect,” they concluded.

The study, “Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study,” was published online in The BMJ.