A Yale-led study published in JAMA Pediatrics finds that second-year medical students who experience mistreatment and discrimination have a higher likelihood of leaving school in subsequent years. Researchers also noticed that recurring mistreatment and discrimination were correlated with higher rates of attrition.
Researchers used a dataset collected by the Association of American Medical Colleges (AAMC) to retrospectively determine how medical school environments may have affected attrition rates for 2014-2015 and 2015-2016 matriculants. The AAMC survey asked second-year students about experiences of behavioral harm, public embarrassment, or being discriminated against based on sex, race, and ethnicity, which the researchers classified into either discrimination or mistreatment.
Departures Triggered by Mistreatment
Students who experienced an isolated incident of mistreatment had an attrition rate of 2.8%. For students who experienced recurrent incidents, that rate jumped to 4.1%. In comparison, students who reported no mistreatment showed a 1.2% attrition rate.
The numbers may actually be underestimated, according to Yale researcher Mytien Nguyen, MSc, because more white and male students filled out the survey than the medical student population. Nguyen hypothesizes that marginalized students may be more disengaged in medical school, leading to fewer survey responses. “The disparity might be higher in reality because we have an underrepresentation of marginalized students in our sample,” says Nguyen. Even so, she says, it is clear that students from marginalized backgrounds were more likely to experience discrimination or mistreatment.
For instance, if 2% of discrimination reports are based on sexual orientation but only 4% of medical students are sexual gender minorities, that is close to 40% of that population reporting instances of mistreatment and discrimination, explains Dowin Boatright, MD, MBA, MHS, assistant professor of emergency medicine and the study’s senior author.
In a 2020 JAMA study of more than 27,000 graduating medical students, researchers found that underrepresented minorities (URM), or students who were female, Asian, multiracial, or identifying as lesbian, gay or bisexual bore the brunt of discrimination. In fact, nearly one in four URM students reported experiences of mistreatment in medical school.
Intervening before students depart
While overt mistreatment has fallen in just the past few years, something he credits to a decrease in implicit bias that several studies have found, Boatright says the prevalence of mistreatment is still “unacceptably high.”
“We know that as we go up the academic ladder, diversity decreases, and so that might be leading to the higher experiences of mistreatment among trainees,” says Nguyen.
Nguyen and Boatright agree that a good place to reduce attrition rates for marginalized students is by diversifying the faculty and leadership at medical schools. Across the nation, fewer than 5% of faculty are from underrepresented groups.
The Washington Medical Commission (WMC), which establishes standards for medical practice in that state, is trying another potential remedy. It is looking at restorative justice, an intervention that involves intense conversation with possible perpetrators of mistreatment and with victims. The goal is so to reach consensus on what actually happened, how these episodes of mistreatment do not only affect the person who was harmed but also the community at large, and opportunities for growth for the person who committed the mistreatment, whether it was intentional or not.
“I think that will go a long way to make faculty, residents, and supervisors more engaged if it’s a growth opportunity, as opposed to being defensive in terms of it being a form of punishment, which I don’t think is what we really want except obviously in the most extreme cases,” says Boatright.
“Trainees are in a very vulnerable position in general, and so I think that how these experiences are resolved is an important aspect,” says Nguyen.
Another solution Boatright has considered is linking pay of either the dean or a hospital’s leadership to diversity metrics such as recruitment and retention of diverse faculty or the prevalence of mistreatment.
“That’s not an exact solution, but I think it will provide a level of accountability that would create a sense of urgency for medical schools and hospitals,” says Boatright.
Reporting Mistreatment More Accurately
Nguyen would like to see more granular reporting, particularly with the Liaison Committee on Medical Education (LCME), since it has influence in the policy for accreditation. Presently, medical schools are not required to report attrition to LCME based on race or ethnicity. She also would like to see studies that go beyond second-year students, as well as more precise reporting on ethnicity—especially for student of Asian descent, whose overall attrition numbers were found to be relatively low.
“I think that warrants more investigation because as we have it, it’s ‘Asian’ as a whole,” says Nguyen. “Asian is a very diverse student population, and I think we need to look at disaggregated Asian subgroups to really understand the influence of mistreatment and discrimination among Asian students.”