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An examination of ethnic minority physician representation in clinical medicine to reduce health disparities among minoritized groups

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An examination of ethnic minority physician representation in clinical medicine to reduce health disparities among minoritized groups

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An Examination of Ethnic Minority Physician Representation in Clinical Medicine to
Reduce Health Disparities Among Minoritized Groups

Lisa Octavia Roberts

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2023

© Copyright by Lisa Octavia Roberts 2023
All Rights Reserved

The Committee for Lisa Octavia Roberts certifies the approval of this Dissertation

Shafiqa Ahmadi
Alison Keller Muraszewski
Esther Kim, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
This study uses the conceptual framework of Bronfenbrenner’s ecology of human development
theory and the motivational framework of Bandura’s self-efficacy theory to understand the
impact of external environmental and internal individual factors that influence persons of color’s
career choices within clinical medicine. The study aimed to identify career indicators that
influence persons of color to pursue clinical medicine, increase diverse representation, and
address health disparities among minoritized patients. Data were collected using 12 semi-
structured qualitative interviews with racially and ethnically diverse active physicians. The
settings from Bronfenbrenner’s ecological framework and the four experiences from Bandura’s
motivational theory that influence individual self-efficacy were applied to analyze the collected
data. Findings from this study showed that external social factors of supportive parents, family,
and mentors had the most significant impact on the individual’s choices. In addition, the desire to
help others, interest in STEM, and self-efficacy of confidence and determination encouraged by
parental role models and ethnic representation were internally driven career indicators. Further
analysis of the healthcare system showed the impact of representation in clinical settings as an
essential factor in countering patient challenges of mistrust, poor treatment adherence, and
systemic discrimination that led to health disparities. This study reviews physicians of color
underrepresentation and its impact on minority health. By identifying essential career indicators,
this study contributes to research that shows the effective influencers to create interventions that
encourage more persons of color to seek a physician career and minimize health disparities
within marginalized communities.

v
Dedication
To Brianna and Mikayla, my two beautiful daughters who are indeed the loves of my life, thank
you for supporting me.

To Warren Semien, my bonus dad, who has always been a consistent and loving support in my
life, I appreciate you.

To my aunt Dora Little, posthumously, who influenced me to be fearless, intelligent, and classy,
and my father, Richard Weaver, who raised me to follow God in all my endeavors.

To my mother Peggy Jeanette Cryer-Semien. You always wanted me to pursue my doctorate but
unfortunately, cancer claimed your bright light and you transitioned shortly after my acceptance
into the program. Dear Mommy, my gratitude and appreciation for you are endless. The care,
love, support, and tenderness you gave me throughout my life helped to shape me into who I am.
You always taught me that I could accomplish anything. Your life served as the blueprint for this
achievement. In your memory, I dedicate this honor to you.

vi
Acknowledgments
I could not have achieved this monumental goal without my loving family and friends.
Your patience, kind words, and unwavering support were critical to my success. Your prayers
carried me through.
To my dissertation committee, thank you for your time, expertise, and thoughtful
feedback. Dr. Kim, thank you for your guidance and helping me cross the finish line. To my
outstanding 12 physician participants. Thank you for giving a voice to our underrepresented
groups in clinical medicine. Thank you to my cohort battle buddies for the endless
encouragement, late-night text messages, and weekly meetings that motivated me to persevere in
this program. Gracias!
Thank you, Dr. Carol Havens, for your mentorship and constant support over the years.
Thank you, Dr. Calvin Wheeler. Your generosity, influence, and exemplary reputation made my
research possible. Thank you to my work family! The recognition, good energy, and
encouragement you provided me during this journey have been invaluable.
Correspondence concerning this dissertation should be addressed to Lisa O. Roberts, 5
Tarn Ct., Hercules, CA. 94547. Email: lweaverr@usc.edu

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
Chapter One: Introduction to the Problem of Practice.................................................................... 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 4
Importance of the Study ...................................................................................................... 4
Overview of Theoretical Framework and Methodology .................................................... 5
Definitions........................................................................................................................... 6
Organization of the Dissertation ......................................................................................... 8
Chapter Two: Literature Review .................................................................................................... 9
Historic Social Determinants .............................................................................................. 9
The Current State of Healthcare ....................................................................................... 22
Addressing the Inequities in Healthcare: Diversifying the Workforce ............................. 29
Conclusion ........................................................................................................................ 36
Conceptual Framework ..................................................................................................... 37
Motivational Framework .................................................................................................. 40
Summary ........................................................................................................................... 41
Chapter Three: Methodology ........................................................................................................ 43
Research Questions ........................................................................................................... 43
Overview of Design .......................................................................................................... 43
Research Setting................................................................................................................ 44

viii
The Researcher.................................................................................................................. 45
Data Sources ..................................................................................................................... 48
Credibility and Trustworthiness ........................................................................................ 52
Ethics................................................................................................................................. 53
Chapter Four: Findings ................................................................................................................. 54
Research Questions ........................................................................................................... 54
Description of Participants ................................................................................................ 54
Research Question 1 ......................................................................................................... 56
Research Question 2 ......................................................................................................... 83
Summary ........................................................................................................................... 94
Chapter Five: Recommendations .................................................................................................. 95
Discussion of Findings ...................................................................................................... 96
Recommendations for Practice ....................................................................................... 103
Limitations and Delimitations ......................................................................................... 110
Recommendations for Future Research .......................................................................... 111
Conclusion ...................................................................................................................... 111
References ................................................................................................................................... 114
Appendix A: Forms of Racism Regarding Racial and Ethnic Disparities .................................. 133
Appendix B: Study Information Sheet ........................................................................................ 137
Introductory Remarks ..................................................................................................... 137
Study of Interest .............................................................................................................. 137
Type of Study .................................................................................................................. 137
Interview Process ............................................................................................................ 137
Interview Questions ........................................................................................................ 138
Interview Protocol ........................................................................................................... 138

ix
The Problem of Practice.................................................................................................. 139
Interview Questions ........................................................................................................ 139
Closing Question ............................................................................................................. 141
Closing Comments .......................................................................................................... 141

x
List of Tables
Table 1: Description of Participants ............................................................................................. 55
Table 2: Kirkpatrick Level 4 Outcomes, Metrics, and Methods for External and Internal
Outcomes .................................................................................................................................... 109
Table A1: Effects of Four Forms of Racism ............................................................................... 133
Table A2: Largest Disparities for Blacks .................................................................................... 134
Table A3: Largest Disparities for Latinos .................................................................................. 135
Table A4: Largest Disparities for Asians.................................................................................... 135
Table A5: Largest Disparities for American Indian and Alaska Natives (AI/Ans) .................... 136

xi
List of Figures
Figure 1: Ecological System ......................................................................................................... 39
Figure 2: The Influencers on Self-Efficacy and Behavior ............................................................ 41
Figure 3: Kotter’s Eight-Step Change Model ............................................................................. 104
Figure 4: Kirkpatrick Evaluation Framework ............................................................................. 108

1

Chapter One: Introduction to the Problem of Practice
The Institute of Medicine’s (Smedley et al., 2004) seminal research on the
underrepresentation of ethnic minorities in the health profession and the impact on health
disparities was one of the first comprehensive studies that focused on this problem of practice.
Their research revealed that the modest growth of ethnic representation over 25 years caused a
significant imbalance where the growing racially diverse population was not reflected
proportionately among healthcare providers (Smedley et al., 2004). Sixteen years later,
disproportionate representation continues. Over 56% of active physicians nationwide are White
compared to 29% of Asian, African American, Hispanic, Native Hawaiian, and Pacific Islander
physicians combined. The remaining 15% comprised multiple races (non-Hispanic), others, and
unknown (Association of American Medical Colleges [AAMC], 2019). The U.S. population is
over 60% White, making the number of physicians closely match that sector of the population,
whereas the number of minority physicians compared to the minority population shows a
physician deficit of 7% for African Americans and 13% for Hispanics (U.S. Census Bureau,
2021a).
Further, racial, and ethnic groups show higher disease incidences in conditions like
diabetes, heart disease, hypertension, and COVID-19. These conditions have caused high
mortality, especially among African Americans who live, on average, 4 years less than Whites.
Specifically, Black men have the most increased mortality compared to other groups (The
Centers for Disease Control [CDC], 2021a). Findings from a research study that sampled over
38,000 family practice physicians, the most prominent delivery platform of care in the United
States, discovered over 50% of uninsured patients that identify as an ethnic minority, have low
income, limited education, and suffer from multiple medical conditions. These individuals are
2

cared for by underrepresented physicians of color compared to less than 10% of these vulnerable
patients cared for by White physicians (Jetty et al., 2022). An underrepresented ethnic minority
physician workforce that overwhelmingly serves groups with the highest incidence of poor
health outcomes could be an effective strategy for eliminating health disparities by increasing the
number of racial and ethnic-diverse providers (Marrast et al., 2014). There is plenty of research
on why minorities do not pursue medicine, primarily environmental causes such as poverty, poor
education, inadequate housing, and discrimination resulting from racial, institutional, and
systemic racism (Lucey & Saguil, 2020). However, despite those formidable obstacles, some
individuals of color persevere to become physicians. Currently, there is limited research that
investigates the reasons why people of color pursue medicine. Discovering career pursuit
indicators for people of color can provide essential data that can help inform how to support the
growth of racial and ethnic-diverse representation in clinical medicine. The extrinsic and
intrinsic reasons why ethnic minorities pursue a career in clinical medicine and the correlation
between their motivations and their commitment to closing the health disparity gap within
minoritized groups are the focus of the study.
Context and Background of the Problem
The professional field of focus for the study is healthcare. The current healthcare system
has evolved over the last century into a structure-based quality improvement ideology where care
delivery deficiencies that impact patients’ health are documented. In addition, designed systems
measure, oversee, correct, and reward healthcare advancements (Marjoua & Bozic, 2012). More
recently, healthcare shifted within the quality sphere from offering micro boutique offerings such
as designed benefits, specialty care delivery programs, and technology to the macro-level focus
of national healthcare like the Affordable Care Act and utilizing retailers as care clinics and
3

telemedicine for routine preventive treatment (Vogenberg, 2019). Unfortunately, within this
movement, patients are marginalized through various social determinants. For example, low
socioeconomic status (SES), lack of insurance, substandard education, risky behavior that leads
to disease, inadequate housing, and restricted healthcare access have seen health inequities grow
or remain the same despite the focus on the quality of care (Adler et al., 2016).
In CYMG Healthcare (pseudonym), the study organization has variation in patient
outcomes that is most prevalent in ethnic minority groups. There are quality initiatives within
inpatient, outpatient, and patient risk and safety departments with specific quality metrics and
targets for each condition within those specialty groups. For example, hypertension is a quality
measure for primary care departments focusing on African American patients. This metric has
remained a priority for several years with no significant improvement. Diabetes in the Hispanic
community is another target area that has been a long-standing focus area with minimal
advancement. Like the national landscape, CYMG Healthcare needs to continue to investigate
this stagnation and perhaps look at the opportunities that diversification may offer in our effort to
stabilize the health of our racial and ethnic communities. With a physician workforce of over
9,000 physicians, less than 25% are African American, Hispanic, Native American, Native
Hawaiian, and Pacific Islander, and over half of CYMG’s patients are culturally and ethnically
diverse. The organization has room for improvement to increase racial and ethnic diversification
to align with the communities served. This study aims to improve healthcare provider
underrepresentation by researching what extrinsic and intrinsic indicators motivate racial and
ethnic groups to pursue clinical medicine and how that relates to their commitment to improved
health outcomes by addressing health disparities within persons of color.

4

Purpose of the Project and Research Questions
The study aims to provide research that illustrates the need for a racial and ethnic-diverse
physician workforce and how their representation can reduce health disparities within
minoritized groups. Health disparities are not new; however, the recent COVID-19 pandemic
highlighted globally the disproportionate health inequities among historically marginalized
groups, particularly those in the Black and Hispanic communities. Pre-existing conditions like
diabetes, heart disease, and asthma affect minorities significantly, making them vulnerable to the
virus outbreak and more susceptible to higher hospitalization and death (Kim et al., 2020).
Titanji and Swartz (2021) indicated that the pandemic illuminated the deep-rooted struggle of
health inequity. They proposed that physicians whose life experiences mirror marginalized
communities are essential to mitigate health inequity by increasing their presence in clinical
medicine. Research exploring the diversification of the physician workforce is critical to
answering the questions related to individual and external factors that influence
underrepresentation. The following research questions will guide the study:
1. What factors influence minorities to choose a career in clinical medicine?
2. How does the representation of ethnic minorities in clinical medicine impact health
outcomes for minoritized patients?
These research questions guide the study by utilizing the conceptual framework of
Bronfenbrenner’s (1979) ecological systems and the motivational framework of Bandura’s
(1997, 2001) self-efficacy as lenses to structure the data collected through qualitative interviews.
Importance of the Study
This problem is critical because health disparities among minoritized groups are a long-
standing public health issue that can become overwhelming without addressing physician racial
5

and ethnic underrepresentation. In collaboration with the CDC, the National Center for Health
Statistics (NCHS) created Healthy People reports beginning in 1980 for each following decade
with specific goals of improvement needed to acquire better living for U.S. residents. Healthy
People 2010 and 2020 both dreamed of reducing and eliminating health disparity, but data
showed that in 10 years, there was no change in health disparities for racial and ethnic groups
(NCHS, 2022). The report associated access to health services with reducing health disparities
and cited consistent patient and provider relationships as an essential pathway to appropriate care
access (NCHS, 2022). With an aging population and anticipated high physician retirement by
2034, the United States will have an estimated shortage of between 17,800 and 48,000
physicians. Physicians from marginalized and underrepresented communities are more likely
than White physicians to practice in underserved areas with a high minority population (Peabody
et al., 2018). Additionally, if national efforts successfully reduce access barriers to care for
minority groups, the physician shortage would increase from 102,400 to 180,400 (AAMC,
2020). Health disparities and inequities, the growing patient needs, access to care for vulnerable
groups, and population considerations that impact public health provide the evidence that
supports the need for physicians, specifically racially and ethnically diverse physician providers.
Overview of Theoretical Framework and Methodology
Bronfenbrenner’s (1979) ecology of human development is the basis of the conceptual
framework for the study. The ecological theory uses four environmental settings as frames or
lenses to critically view how the external environment connected to the individual influences
their behavior. In the context of the problem of practice, this study will apply each setting to
examine the underrepresentation of minority physicians, the impact of the lack of ethnic diversity
in addressing health disparities, and indicators for career pursuit in clinical medicine. Bandura’s
6

(1997) self-efficacy theory is the motivational framework used to address the lack of ethnic
minorities in healthcare. Self-efficacy is an individual’s belief in their skills to control their
behavior and external events to achieve a goal. Applying self-efficacy theory will show how
negative self-perceived thoughts can directly affect individual agency, motivation, and self-
regulation. Lack of self-efficacy can undermine potential pursuits of a medical career and further
deepen the gap in ethnic minority representation within healthcare. The methodology is
qualitative, using 10-question semi-structured interviews for data collection. Participants will
comprise 12–20 ethnically diverse active physicians employed at CYMG and other large
healthcare organizations. This group is essential for the study because their knowledge, attitudes,
experience, and insights are essential to answering the research questions and highlighting key
concepts for the analysis.
Definitions
The definition of critical terms will provide clarity of meaning, giving readers a further
understanding of vocabulary and concepts commonly used but not widely understood in the
study of racial and ethnic underrepresentation in clinical medicine.
Active physicians are licensed doctors of medicine (MD) or osteopathic medicine (DO)
by one of the 50 U.S. states, the District of Columbia, or Puerto Rico. They work 20 hours or
more per week in direct patient care, administration, medical teaching, research, and other
nonpatient care activities are considered active (AAMC, 2020).
Diversity relates to the representation and relative size of various racial and ethnic groups
within a population (U.S. Census Bureau, 2021b).
Health disparities are diseases, injuries, and violence that are preventable and
experienced by socially disadvantaged populations from achieving desired health (CDC, 2020).
7

Health inequities refer to systematic variation in the health status or the supply of health
resources between different groups resulting from social conditions that impact how people are
born, develop, live, work, and age (World Health Organization [WHO], 2018)
Medical interns, or PGY-1 (post-graduate Year 1), are 1st-year residents or interns;
beyond that, they become residents (Medical University of the Americas [MUA], 2021).
Medical residents are medical school graduates with an MD or DO degree in a post-
graduate training program accredited by the Accreditation Council for Graduate Medical
Education (MUA, 2021).
Minority does not mean less or deficient when referring to race; it is a subgroup of the
population with ethnic, racial, social, religious, or other traits that are different from the majority
population (APA, 2020).
Persons of color are any non-White or mixed-race person (Merriam-Webster, n.d.-c).
Racial ethnic, per the American Psychological Association (APA, 2020) “refers to
physical differences that groups and cultures consider socially significant, and ethnicity refers to
shared cultural characteristics such as language, ancestry, practices, and beliefs” (p. 142).
Residency is the stage of training where medical residents work in medical settings
(medical offices or hospitals), providing patient care under the supervision of an active practicing
physician to continue their education and medical training within a specialty of their choice
(MUA, 2021).
Underrepresented minority (URM) refers to historically underrepresented racial/ethnic
groups. These groups include Black (i.e., African American, Caribbean American), Latinx
American (i.e., Mexican American, Puerto Rican), and Native American (i.e., American Indian,
Alaska Native, and Native Hawaiian; AAMC, 2020).
8

Underrepresented minority in medicine (URiM), in an expanded definition, specifically
describes racial and ethnic populations underrepresented in the medical profession relative to
their numbers in the general population (AAMC, 2020).
Organization of the Dissertation
The dissertation details the study and uses five chapters to organize the content. Chapter
One provides an overview of the problem of practice, including the background of the problem,
the purpose of the inquiry, research questions, research importance, conceptual and motivational
frameworks, definitions of key terms, and dissertation organization. Chapter Two is the literature
review. This section provides an in-depth, comprehensive dive into the existing empirical
research about the problem in practice and descriptions of the conceptual and motivational
frameworks and their applicability to the study. The reviewed literature explores the historical
influences, the current state of healthcare, and an examination of an ethnically diverse physician
workforce. Chapter Three describes the methodology used to gather data based on the research
questions for the study. The methodology components include research setting, data sources,
collection procedures, reliability, ethics and limitations, and delimitations. Chapter Four will
document and summarize the findings of the 12–20 qualitative interviews and secondary data
from existing government and organizational documents to triangulate the findings for credibility
and trustworthiness. Chapter Five will analyze the results and provide recommendations for
practice and future research.

9

Chapter Two: Literature Review
This literature review examines research on the underrepresentation of ethnic minority
physicians in clinical medicine. This section begins with an overview of social determinant
factors contributing to low ethnic minority representation in healthcare. It then explores these
factors and their impact on the current healthcare system. Subsequently, the review uncovers the
influence of health disparities, lack of access to care, and mistrust that results from
underrepresentation. The final portion of the literature review centers on research that explains
challenges addressed through ethnic diversification of the physician workforce. Analysis
revealed that increased physician presence in medically underserved areas, provider-patient race
concordance, and supportive institutional practices to increase the number of physicians needed
for future population growth are effective methods to counter these challenges. After the research
synopsis, the conceptual framework application of Urie Bronfenbrenner’s (1979) human
development ecological systems and Albert Bandura’s (1997) self-efficacy motivational
framework are theoretical lenses to interpret the problem of practice.
Historic Social Determinants
The definition of underrepresented minority (URM) in the medical field was established
more than 20 years ago by the AAMC. The phrase “underrepresented minority” refers to Black
(i.e., African American, Caribbean American), Latinx American (i.e., Mexican American, Puerto
Rican, Cuban, South, and Central American), and Native American (i.e., American Indian,
Alaska Native, and Native Hawaiian). AAMC has broadened its definition to describe those
underrepresented in medicine (URiM). This new definition specifically describes URiM as
“racial and ethnic populations underrepresented in the medical professions relative to their
numbers in the general population” (AAMC, 2020). Despite efforts to increase ethnic diversity
10

among physicians in the United States, the current composition of clinical staff has not
significantly changed for over 20 years (Freeman et al., 2016). Various long-standing social
determinants that create generational challenges prohibit ethnic minority success in healthcare
and other professions related to science, technology, engineering, and math (STEM). The
following section will review the social determinants of racism, education, higher education,
self-efficacy, and mortality and their role in reinforcing the issues that underpin the lack of
minority representation in clinical medicine.
Racism
Historically the construct of race has been used mainly in the United States to exclude
ethnically diverse groups from progress. Paradies et al. (2015) defined racial discrimination as
societal structures designed to impose barriers that prevent ethnic minorities from attaining
opportunities, resources, and influence equal to their White counterparts. The study shared that
people can internalize racism within their worldview perceptions, interactions with groups, and
systems such as employment, education, and housing (Paradies et al., 2015). In addition,
negative stereotypical representations in media reinforce discriminatory viewpoints and may
endorse unfair treatment resulting in adverse cognitive, behavioral, social, and health changes
within ethnic groups (Brondolo et al., 2011). The construct of racism resides within four societal
cornerstones that continue to perpetuate exclusion and discrimination. Structural, cultural,
institutional, and individual forms of racism serve as pathways that lead to various psychological
outcomes, resulting in significant disparity for ethnic groups (Harrell et al., 2011).
As shown in Table A1 (see Appendix A), the internal psychological representation and
mediators of physiological impact are illustrated for each form of racism, along with examples
demonstrating the outcome associated with structural, cultural, institutional, and individual
11

racism. Various study findings support that these forms of racism exist and significantly impact
African Americans. For example, data from the U.S. Census income and poverty report
documented by Shrider et al. (2021) showed evidence of structural racism in outcomes. Findings
revealed that median income and educational attainment are the lowest, and poverty levels are
the highest for African American households, with no statistical difference between 2019 and
2020. In their report, Race in America, Pew Research Center (Horowitz et al., 2019) used an
online questionnaire to survey over 6,600 adults in English and Spanish regarding U.S. race
relations and inequality. Evidence of individual racism indicated that 84% of African Americans
perceived prior enslavement and race discrimination as significant obstacles that prevented their
ability to attain economic security, education, and housing (Horowitz et al., 2019). Additional
findings revealed that over 50% of U.S. citizens believed belonging to specific ethnic groups,
specifically Black or Hispanic, is a significant obstacle to advancement and achievement
(Horowitz et al., 2019). Another study by Bowser (2017) stated that cultural and institutional
racism project biased ideologies that champion unfair practices that target minoritized ethnic
groups but differ in how they operate. Societal values and norms that uphold White supremacist
ideology is cultural racism, whereas institutional racism involves structural barriers that suppress
advancement within schools, housing, and employment (Bowser, 2017).
Evidence suggests that racial discrimination has prevented progress for ethnic groups
from having representation in all sectors, particularly in medicine (AAMC, 2020). Racial
discrimination in educational institutions has undermined academic achievement for persons of
color. Historic labels used in educational settings, for example, “slow learners” and “students
with special needs,” were reserved to describe Black children, and “backward children” was used
to describe Hispanic students. These discriminatory labels persist, evidenced by the
12

disproportionate number of minoritized children in these categories (Frenkiewich & Onosko,
2020). Research suggested schools’ racial climate and ethnic minority students’ perception of
racial fairness are principal indicators of academic attainment and fulfillment of educational
aspirations (Griffin et al., 2017).
Education
Reviewed literature indicated that a lack of academic preparedness for African American,
Hispanic, or Native American students hinders eligibility for STEM-related careers (MacPhee et
al., 2013). The National Center for Education Statistics (NCES) researched educational trends
and revealed that 75% of public-school K–8 enrollment are ethnic minorities. The reading
achievement gap between White and Black students has not changed in 25 years, and the Black
and Hispanic math achievement gap has stayed statistically the same for over 25 years. Black
students trail White students by 25 points and Hispanic students by 19 points (de Brey et al.,
2019). These low literacy patterns place Black and Hispanic students entering high school 5
years behind with no remedial instruction available to close the gap (Reardon et al., 2012). Low
literacy is essential to note because literacy is vital to social mobility, socioeconomic growth, and
individual academic success (Reardon et al., 2012).
Literature shows that challenges in academic achievement connect to race and discipline.
For example, low achievement and discipline challenges mainly occurred in urban ‘majority-
minority’ schools where students of color who experienced out-of-school suspension are at
higher risk for poor educational outcomes (Nation et al., 2020). In 2013-2014 over 2 million
students in public schools received one or more out-of-school suspensions. Thirteen percent of
Black students had the highest suspension rate, more than any other ethnic group, followed by
6.7% of American Indian and Alaska Native, 5.3% of mixed-race students, and 4.5% Hispanic
13

and Pacific Islander students (de Brey et al., 2019). The consequence of suspension deprives
students of an educational environment that prepares them for academic success and fosters
negative attitudes towards school, which can lead to poor performance and school dropout
(Fabes et al., 2021).
High school dropout trends are also associated with homelessness, truancy, and
absenteeism, which widens the achievement gap for minoritized students (Mireles-Rios et al.,
2020). Almost 8 million students in the United States are chronically absent, and each week a
student is absent from school, the likelihood of completing high school drops by 20% for every
missed week (Jordan, 2019). High school dropout demographics show that males drop out more
than females, African Americans and Latinos drop out higher than Whites and Asians, and those
from low-income households drop out more frequently than those from higher-income families
(Rumberger, 2020). In 2016, Latinos experienced the highest drop rate of 9%, followed by 6% of
Black students (de Brey et al., 2019). Among minority adults in the United States, Latinos 25
years old and up had the highest non-completion rate for high school than any other group
(Nation et al., 2020). Continual socioeconomic status (SES) factors add to the underlying
problems of education attainment. Within minority neighborhoods, low income, elevated home,
and school transition rates, consistent crime, minimal resources, and low self-confidence among
students to oppose challenges undermine student success (McBride Murry et al., 2011). Another
pivotal characteristic of education is the role of educators. Research indicates that teachers of the
same race and ethnicity as their students positively impact their attitude and motivation.
Conversely, White teachers with less connection and empathy for students of color can adversely
influence student attitudes and motivation (de Brey et al., 2019).
14

Teachers within an educational environment can either support or deter achievement gaps
among minority students. Using the General Social Survey, Quinn’s (2017) research stated that
personally invested educators provide students of color quality education, work with a broadly
racially diverse staff, and the student body has fewer racial stereotypical perspectives. In
addition, personally invested educators are more generous in explaining racial inequalities and
impose less resentment and social distance toward people of color than noneducators. Starck et
al.’s (2020) research study supported these previous findings; however, the article acknowledged
that teachers and non-teachers who embrace explicit and implicit racial biases rooted in White
supremacist ideology could impact students of color. Tenenbaum and Ruck (2007) conducted
meta-analyses that reviewed teachers’ four behaviors towards minority and White students:
expectations, referrals, positive reinforcement, and negative reinforcement. Results showed three
areas differed between underrepresented students and White students. Teachers who favored
White students displayed positive expectations, positive referrals, less undesirable referrals, and
neutral speech, which did not extend to African American and Hispanic students (Tenenbaum &
Ruck, 2007). Another study examined the results from the Project Implicit website spanning
between 2002 to 2012, which logged over two million scores on the White and Black Implicit
Association Test. Participant demographics included over 70% White, less than 10% Black,
Hispanic, Asian, mixed-race, and less than 1% Native American. Analysis of this study
concluded that bias differed by geography. In locations with high numbers of Black students,
teachers showed lower preference than in areas with high disparities in suspension, which
revealed a higher level of bias (Chin et al., 2020; Xu et al., 2014). Adair (2015) described
overcrowding, minimal resources for quality ESL programs, and less skilled, low-performing
teachers contributed to students’ poor academic performance. In addition, the study showed
15

communication is difficult between teachers and immigrant families due to a lack of
understanding of cultural differences. Adair (2015) concluded due to proficiency test
misdiagnoses, ESL students are put in special education classrooms or evaluated as learning
disabled.
The literature provides evidence-based data demonstrating barriers within the K–12
education system that block essential education and skill training for students of color. For
example, low literacy, disproportionate suspensions, absenteeism, high school dropout rates,
teacher influence on achievement, and socioeconomic disparities impact minority student
competence and contribute to the lack of preparation for a career in clinical medicine. Moreover,
for those minority students that can advance and enter college, discriminatory treatment
continues to be a factor that undermines academic achievement and clinical career pursuits.
Higher Education
In higher education, studies concluded that the central success blockades for minority
students include discrimination, cultural and social isolation, language, and underrepresentation
of ethnic minorities in academic institutions and clinical facilities (Naidoo et al., 2020). A
research study that involved over 200 undergraduate STEM college students of different ethnic
backgrounds showed that subtle, indirect discrimination, known as microaggressions from peers,
teachers, and administrators, decreased school interest among minority students. Self-defeating
behavior like dropping classes, changing majors, and leaving college reflected student reactions
to unsupportive campus life (Byars-Winston et al., 2010). These microaggressions contributed to
students of color developing a limited mindset that opposes growth and advancement. Research
by Dr. Carol Dweck (2008) discussed the theory of fixed and growth mindsets and their impact
16

on achievement. A fixed mindset is risk-averse, convinced that skill, intelligence, and
capabilities do not expand with no room for further cultivation.
Conversely, a growth mindset believes intelligence is expansive and can continue
developing and improving (Dweck, 2008). Growth thinking is not opposed to risk but uses that
space as an opportunity to learn and build (Honey & Kanter, 2013). Canning et al. (2019)
conducted a longitudinal survey that included 150 university STEM teachers and over 15,000
students who researched fixed mindsets and their impact on STEM achievement. Study
outcomes showed that faculty with a fixed mindset doubled the achievement gaps among their
students as opposed to students with professors with a growth mindset. Further analysis of course
evaluations showed students were not motivated and experienced more adverse outcomes from
instructors in the fixed mindset group. Achievement predictions were more closely associated
with faculty mindset than characteristics of gender, age, ethnicity, teaching experience, or tenure
(Canning et al., 2019). These beliefs imply that the experiences and achievements of
underrepresented students in STEM impact their mindset. Racial bias, limited financial
resources, lack of mentors, and discriminatory attitudes influence mindsets and create barriers
that dissuade ethnic minorities from pursuing medicine.
Research revealed that students interested in a medical career hesitated to pursue
medicine because of racist attitudes they feared would come from White physicians and patients
(Rao & Flores, 2007). Freeman et al. (2016) conducted a qualitative research study to identify
barriers minority students interested in healthcare face in pursuing a medical career. In the
research, minority students cited minimal guidance from college administrators on pursuing
medicine as a career, lack of personal and family financial resources, societal discriminatory
attitudes, and no access to mentors caused diminished interest in medicine. These barriers
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disadvantage students of color and prevent them from competing in the industry. A student of
color from the study shared their future perspective on getting hired in a healthcare system:
but there are students every year who don’t get matched. And they try next year, and they
still don’t get matched. And then where do you go? What happens if you never get
matched, I guess? Because that’s a possibility and you don’t go through residency, so
you’re stuck with an MD who can’t practice medicine. (Freeman et al., 2016, p. 989)
Trends for African American college students, especially Black male undergraduates, resemble
K–12 outcomes of poor academic performance. de Brey et al. (2019) reported that among all
ethnic groups, Black men have the lowest community college and university graduation rates,
with 33% and 36%, respectively. In the 2017-2018 school year, STEM programs conferred
31,802 certificates and degrees to African American males compared to over 260,000 STEM
degrees earned by White male students, which is a difference of 56%, with Black students
overall attaining the 2nd lowest number of STEM degrees (de Brey et al., 2019).
Research showed education provides significant barriers for ethnic minorities pursuing
medical sciences beginning in the lower elementary grades through undergraduate programs.
Achievement gaps influenced by low literacy, disproportionate out-of-school suspensions, high
school drop rates, discriminatory attitudes, and microaggressions from peers and teachers are
among many contributing factors that increase the lack of representation of ethnic minority
physician providers in healthcare. In addition, personal and academic self-efficacy factors also
reveal internal struggles that complicate educational attainment.
Self-Efficacy
Research disclosed that low self-efficacy could be one of the barriers to achievement,
whereas high efficacy can serve as a path to personal agency and favorable outcomes (de Brey et
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al., 2019). Bandura (1997) described self-efficacy as the perception of one’s personal belief in
their capabilities to organize, execute and accomplish a goal. Academic self-efficacy is the
ability to achieve academic responsibilities confidently. This area of advocacy encompasses
external attributes of vicarious learning, social experiences, and verbal reinforcement from
powerful influencers that impact internal self-judgment, competence, and expectations related to
occupational pursuits (MacPhee et al., 2013). A research study collected data from four ethnic
groups of biological science and engineering undergraduates to analyze their self-efficacy, goals,
and outcomes within their major. Findings showed that self-efficacy is a positive method to deter
adverse environmental effects; a strong sense of personal ethnic identity and connecting with
individuals within your ethnic community bolsters confidence (Byars-Winston et al., 2010).
Students actively involved in the learning process and exhibit self-efficacious behavior in
educational settings do well academically. Students with lower self-efficacy are not motivated,
adversely impacting their achievement (Pajares, 1996, 2002). Minority students with low SES
have double minority status. Students with multiple adverse indicators are more inclined to have
lower academic self-efficacy and performance than students with only minority status, such as
ethnicity (MacPhee et al., 2013). African American students’ multiple indicators make them
more susceptible to poor self-efficacious behavior. Historical implications of inequity in
education among African American students directly affect beliefs of accomplishment, which
has led to a 12% high school dropout rate compared to 6% for White students (Schunk &
Mullen, 2012). Black men are affected by poor personal perceived beliefs that dampen self-
efficacy. Research showed that Black men who experience discrimination and negative societal
attitudes are prone to internalize undesirable imposed labels, impacting self-judgment and
success (Reid, 2013). Okech and Harrington (2002) studied the relationship between Black
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consciousness and academic self-efficacy. Using Milliones’ (1980) Developmental Inventory of
Black Consciousness, the authors applied this assessment which contains four stages
(preconscious, confrontation, internalization, and integration) to survey 120 Black male college
students. They discovered students who identified in the integration stage had positive attitudes
toward being Black, embraced their culture, were proud and not threatened by White culture, and
had higher academic self-efficacy than Black men in the preconscious stage. This stage included
Black men not involved in pursuing Black consciousness and internalized racist stereotypes of
Black people. Another study revealed that successful academic integration directly determined
Black male college students’ math efficacy. The researchers in this study stated that talking with
faculty, meeting with an advisor, studying in the library, and time status (full or part-time) were
indicators of academic integration, strengthening self-efficacy in college-level math (Wood et al.,
2015). A study of over 300 Hispanic graduate students disclosed that mentoring was an
important component of positive self-efficacy. Like African American students, having
community and relationships with mentoring faculty increased academic self-efficacy compared
to non-mentored Hispanic students, who showed a regression of 24% (Holloway-Friesen, 2021).
Though existing barriers for students of color pursuing healthcare careers are apparent, self-
efficacy and a strong belief in their ability to succeed can effectively address these challenges
(Yelorda et al., 2021). A mixed-methods study of ethnically diverse low-income high school
students interested in STEM careers participated in focus groups and completed self-efficacy
questionnaires. Findings concluded students who scored high for self-efficacy used strategies for
academic success, focused on future goals, asked for help and were persistent in addressing
academic challenges. Those with low self-efficacy scores perceived barriers, finances, negative
cultural values, and racism in the medical field are too hard to overcome; therefore, students lose
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interest (Yelorda et al., 2021). Minimal self-efficacious behavior in academic settings can hinder
the diversification of the clinical workforce, along with many other factors contributing to the
underrepresentation of minorities in healthcare. For African American representation, mortality
is an important issue to consider. With a death rate higher than any other ethnic group, African
American mortality is essential in the study of ethnic minority physician underrepresentation in
clinical medicine (CDC, 2017).
Mortality
Research indicated that chronic diseases like heart disease and diabetes emerge earlier in
life among African Americans than Whites and other ethnic groups. Cancer is devastating,
causing a shorter life span and a higher death rate in African Americans than in Whites
(Cunningham et al., 2017). COVID-19 has illuminated the steep disparities in ethnic minority
communities with startling mortality numbers. In 2020 the CDC reported that African American
and Hispanic populations comprised over 55% of COVID-19 cases. In those same ethnic
communities, because of poverty, lack of equal access to healthcare, and pre-existing health
conditions, African American and Hispanic individuals are disproportionately more likely to die
from COVID-19 than White individuals (Greenaway et al., 2020). In addition, Black men have
high mortality rates. In fact, “Black men have the highest mortality of any large minority group
nationally. Homicide among Black males is the top cause of death between ages 15–34” (Martin
et al., 2015, p. 1415). In unintentional deaths, car accidents have decreased among African
American, Hispanic, and other ethnic young adult groups; however, accidental deaths due to
drug overdose increased in White, Black, and Hispanic young adults, resulting in over 2,000
additional deaths in 2015. Intentional deaths increased for all races and ethnicities, with a notable
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increase in drug-induced suicide among Black and Hispanic youth. As a result, 1,400 additional
suicides occurred in 2015 (Khan et al., 2018).
The pool of potential ethnic minority physician candidates is limited due to increased
disease, accidents, and homicide, resulting in higher mortality. Mainly, related to Black men’s
mortality is a significant cause of Black male underrepresentation in clinical medicine
(Laurencin & Murray, 2017). In addition, improving workforce diversity under the current
climate of hiring and workplace conditions within healthcare poses another obstacle for
emerging underrepresented clinical medicine providers.
Hiring Practices and Workplace Issues
Evidence suggests disparities in hiring practices and workplace issues for different ethnic
groups. Davis and Allison (2013) reported that 7.2% of Black medical school graduates were
denied opportunities due to race, unlike White medical school graduates, that only cited 0.6% of
racial discrimination. In STEM careers, the Pew Research report (Funk & Parker, 2018) on
workplace equity showed that 62% of African Americans experienced a higher incidence of
discrimination in STEM-related jobs compared to 44% of Asians and 42% of Hispanics. The
report further revealed African American sentiment toward career advancement; 40% cite that
race prohibits job success, 78% believe discriminatory hiring practices limit African American
employment, and 75% believe race prohibits promotion (Funk & Parker, 2018). Using the Sexist
Microaggression Experience, Stress Scale, and Racial Microaggression Scale, researchers
surveyed a diverse group of surgeons and anesthesiologists who work in a large health
maintenance organization (Sudol et al., 2021). Over 650 physicians replied, which resulted in a
41% response rate. Study outcomes revealed that 94% of female physicians experienced a
greater prevalence and severity of sexist microaggressions, and 81% of underrepresented
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minority male and female physicians experienced racial and ethnic microaggressions (Sudol et
al., 2021). Female physicians from an underrepresented ethnic group reported higher incidences
of physician burnout because of sexist and racial microaggressions they experienced due to their
intersectionality (Sudol et al., 2021). The association between gender, ethnicity, and pervasive
microaggressions highlights discriminatory treatment and workplace inequity (Sudol et al.,
2021).
The historical and present challenges of racism, inadequate education, low self-efficacy,
mortality, hiring, and workplace conditions are significant barriers to increasing the number of
minority physicians in clinical medicine. Analysis of present-day healthcare illustrates critical
challenges that continue to put our patients at risk and burden our systems. Health disparities,
lack of access, and mistrust are factors that ethnically diverse providers can address.
The Current State of Healthcare
In 2019 the world experienced its first pandemic in 100 years. COVID-19 took lives and
showed the fragility of our healthcare system. Underserved communities were significantly
affected by COVID-19, with Black, Latino, and Native American communities experiencing
disproportionately high hospitalization and death (Tai et al., 2021). The social, environmental,
and medical issues before the pandemic became more apparent during this crisis. Diabetes,
hypertension, cardiovascular disease, and pulmonary disease are co-morbidities that plagued the
African American and Latino communities in high numbers pre-COVID, making these groups
more susceptible to hospitalization and death when infected by the COVID-19 virus (Alcendor,
2020). Health disparities, lack of access, and mistrust exasperated our current healthcare systems
and underscored the need for more providers, especially physicians of color.

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Health Disparities
An ethnically diverse physician workforce is a viable strategy to improve care outcomes
through better access, culturally responsive care, and reducing health disparities (Walker et al.,
2012). Henke et al. (2015) conducted a study that evaluated health disparities among racial and
ethnic employees who work in U.S. organizations. Favorable health benefits, good income, and a
safe work environment did not exempt certain employees from experiencing health disparities
(Henke et al., 2015). Among the medical conditions included in the study, Native Americans and
African Americans had the highest incidence of almost 50% of medical conditions. Additionally,
Henke et al. (2015) measured four health risk factors: obesity, blood pressure, safety belt use,
and physical activity. Findings showed that African American employees had the highest
numbers within these risk factors out of all the ethnic groups evaluated (Henke et al., 2015).
Davis et al.’s (2017) research speculated that external work factors like education, housing,
attitudes toward healthcare, and lifestyle choices could influence the existence of health
disparities. The study showed differences in chronic diseases based on race, with Latinos (29%)
having the highest prevalence of diabetes compared to 17% of Whites. Cancer showed an
increased incidence among White individuals at 17%, with African Americans at 12% and
Latinos at 9%.
Still, African American cancer patients experienced lower life expectancy and mortality
than any other group (Davis et al., 2017). Disparities began to decrease nationally from 2000 to
2018. However, patients with multiple chronic conditions increased for African Americans and
worsened for poor and uninsured communities (U.S. Department of Health and Human Services
(DHHS), 2019). The DHHS (2019) published the 2018 National Healthcare Quality and
Disparities Report, a research document required by the U.S. Congress to provide a complete
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analysis of healthcare quality received by U.S. residents and care disparities that impact racial
and ethnic communities within low socioeconomic groups. White population outcome data were
used as a baseline to compare results from each racial-ethnic group. Tables A2–A6 (see
Appendix A) outline the study results of the top disparities from each ethnic group. The most
significant health disparities for Blacks and Latinos are new HIV cases and deaths.
Additionally, for Black children ages 2–17, asthma hospitalization, and for Latinos, the
flu vaccine for home health patients. American Indian and Alaska natives also reported a
significant increase in new HIV cases but showed this group’s highest infant mortality as a
distinct health disparity. Native Hawaiians and Pacific Islanders, and Asians report a discrepancy
in home health workers treating them with courtesy and respect during their last 2 months of care
(DHHS, 2019). Most recently, between 2019–2022, health disparities among ethnic minorities
became globally highlighted due to the onset of the COVID-19 virus.
African Americans and Latinos have been excessively affected by COVID-19 due to
underlying co-morbidities; diabetes, cardiovascular disease, asthma, HIV, obesity, and
overcrowded living conditions that limit social distancing (Hooper et al., 2020). A cross-
sectional study using the COVID-19 Tracking Project and the CDC discovered that across the
United States, COVID-19 infection and death rates were higher among racial/ethnic communities
than Whites in all age groups. Especially those under 65 years and social vulnerability of
increased exposure due to poverty and living conditions were predictors in several marginalized
counties (Boserup et al., 2020). The impact on employment due to COVID-19 affected ethnic
minority groups who mainly worked in public service occupations classified as “essential,”
which constantly exposed them to the virus (Rothman et al., 2020). Numerous immigrants and
25

undocumented individuals did not have access to primary care physicians and therefore used
emergency rooms or did not get treatment (Rothman et al., 2020).
Health disparities among ethnic minorities pose a significant challenge to our healthcare
system. Increased representation of racially diverse physicians in the medical workforce pipeline
is greatly needed to improve patient outcomes. In addition to health disparities, lack of access to
medical services preventing at-risk communities from receiving timely care is another challenge
to healthcare systems.
Lack of Access
Access to care can be elusive in certain parts of the country, especially in rural and
remote U.S. areas (CDC, 2021b). Considered highly vulnerable by the CDC’s social
vulnerability index, residents in rural communities have housing, transportation, poverty, race,
and language barriers. These conditions make rural residents more susceptible to poor health
outcomes (CDC, 2021b). The CDC (2021b) reported that an estimated 46 million people live in
rural communities within the United States. Residents are at high risk for chronic illness due to
elevated cigarette smoking rates, obesity, hypertension, and health systems failing to address
health disparities and social inequities like minimal health insurance limiting access to care
(CDC, 2021b). Rural Healthy People 2020 surveyed over 900 residents about health priorities in
their rural communities. Among 76% of the respondents, healthcare access was the most critical
priority for the rural community (Bolin et al., 2015). Globally other countries have challenges
with providing timely care to their citizens. However, in the United States, the lack of access is
emphasized. An international survey of 11 countries showed that U.S. respondents are more
likely than other countries to not seek care due to cost, regardless of health insurance. This lack
of access has worsened disparities in health outcomes for minoritized groups.
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The National Healthcare Quality and Disparities Report (NHQDR) analysis of U.S.
healthcare quality and health disparities evaluated access to healthcare and the distinctions that
prevent access to care. The NHQDR defined healthcare access as “the timely use of personal
health services to achieve the best health outcomes” (DHHS, 2019, p. A1). Findings showed that
between 2000-2018 the factors that contributed significantly to poor access among ethnic
minorities were lack of health insurance and patient perception of healthcare needs (DHHS,
2019). In 2019, close to 30% of Hispanic and over 14% of Black adults lacked health insurance
compared to 10.5% of Whites and 7.5% of Asian adults that lacked health insurance (DHHS,
2019). The next contributor to lack of care access is defined by the WHO as “perceived health
need is the need for health services as experienced by individuals and may or may not coincide
with professionally defined or scientifically confirmed needs” (DHHS, 2019, A17). The NHQDR
states clinical outcomes are the focus of perceived health needs, not patient satisfaction, and the
barriers that prevent patients from participating in the experience of receiving care (DHHS,
2019). The NHQDR indicated that adults and children who were poor, low-income, Black, and
Hispanic adults had more difficulty securing routine healthcare appointments or specialist
appointments than Whites (DHHS, 2019). Over 20% of Blacks and 19% of Hispanics reported
no regular care was received when needed compared to 14% of Whites and 20.4% of Blacks, and
over 24.3% of Asians reported appointments with specialists did not happen compared to 14% of
White patients (DHHS, 2019). Perception of needs about children’s healthcare, 8.8% of Black
children and 6.6% of Hispanic children did not have routine appointments compared to 4.5% of
White children (DHHS, 2019).
Social inequities (poverty, race/ethnicity, geography) and decades of systemic healthcare
discrimination limit patients’ access to care. These experiences of systemic discrimination also
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led to mistrust among marginalized groups whose encounters with inferior healthcare have
fostered skepticism in providers and healthcare institutions (Griffith et al., 2021). Increased
representation of medical providers that understand these issues from an ethnically shared
experience is an opportunity to address medical care doubts effectively.
Mistrust
Uncertainty about the care experience is related to low trust in the healthcare system and
physician providers. Patient mistrust is associated with reluctance to seek care, lack of
satisfaction, discomfort sharing sensitive information, inconsistent treatment compliance, and
follow-up (Wiltshire et al., 2011). Data analysis findings from 704 Black, 711 Hispanic, and 913
White adult responders of the Survey of California Adults on Serious Illness and End of Life
2019 showed race, ethnicity, and perceived discrimination prominently associated with medical
mistrust. Blacks had 73% higher mistrust attitudes, and Hispanics had 49% mistrust attitudes
compared to over 53% of White patients who declared high trust in their doctors (Bazargan et al.,
2021). The following year, researchers evaluated the same data from the Survey of California on
Serious Illness and End of Life and analyzed end-of-life preparedness. Data from Black (24%)
and Hispanic (34%) patients who identified one or more serious medical conditions expressed
that if their medical status worsened, they were unprepared, unlike 19% of White patients.
Findings revealed that when medical mistrust and low health provider communication about
patient emotional issues of fear and sadness, race and ethnicity were associated with a lack of
preparedness (Bazargan et al., 2022).
Mistrust is higher in ethnic minority encounters, specifically with African Americans.
The historical and current discrimination practices experienced by African American patients
within healthcare make trust-building difficult (Cuevas & O’Brien, 2019). A focus group study
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of African Americans’ reasons for distrust of medicine included racism, economic discrimination
due to low-income status, and disregard of Black bodies through experimentation, citing the
Tuskegee Syphilis experiment as an example of intentional neglectful medical practice (Jacobs et
al., 2006). The official study was called the Tuskegee Study of Untreated Syphilis in the Negro
Male, where doctors purposely withheld penicillin treatment from Black men with syphilis
without their consent so researchers could study the natural progression of the disease (CDC,
2021c). Praised as a contribution to gynecological surgery, Dr. Marion Sims conducted surgical
experiments on three enslaved women without anesthesia. Each enslaved woman underwent up
to 30 surgeries over 4 years as part of Dr. Sims’ research (Wailoo, 2018). The study showed that
historical and current knowledge of unethical mistreatment of African American patients
predisposes individuals with a strong racial identity to be sensitive to covert social cues. Ninety-
five percent of research participants believed those who experience microaggressions are least
likely to trust the healthcare system and concluded societal perception that African Americans
are inferior, which further solidified their mistrust of healthcare institutions (Cuevas & O’Brien,
2019). Earlier research from Cuevas et al. (2016) documented results from African American
focus groups that explored patient experiences and relationships in healthcare. This research
revealed that patients feel discrimination before seeing the doctor, and extended wait times cause
African American patients to feel mistreated. Specifically, African American women noted that
staff interacted ‘warmly’ towards White patients instead of Black patients (Cuevas et al., 2016).
Health outcomes can be impacted unfavorably by a general mistrust of healthcare and make
interactions uncomfortable with physician providers (Cuevas et al., 2016). Wiltshire et al. (2011)
conducted a cross-sectional analysis of 3,649 African American patients who responded to a
survey of provider trust. Research findings noted that most Black men and women with low trust
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scores did not graduate from high school, are at least 65 years old, and do not have a consistent
source of care. The reluctance due to mistrust creates untimely healthcare interventions,
especially among African American men, who trend higher for medical mistrust than other
groups, according to public health research (Alsan et al., 2019). Barriers of mistrust lead to
disbelief in diagnosis, poor medication adherence, and distrust of physicians and the healthcare
system (Hall & Heath, 2020).
The challenges of health disparities, limited access to care, and mistrust significantly
impact our current healthcare systems. The Institute of Medicine states that an increased
physician supply of ethnically diverse providers practicing in medically underserved areas can
help eradicate health disparities among our socio-economically challenged, uninsured racial and
ethnic communities (Walker et al., 2012). Increased representation of ethnic minorities as
physician providers is a practical approach to improving health outcomes in our communities.
Addressing the Inequities in Healthcare: Diversifying the Workforce
A diversified physician workforce that reflects the various ethnically diverse populations
would help address inequity in healthcare (Marrast et al., 2014). An ethnic minority physician
can minimize health disparities in vulnerable groups by addressing the demands of population
growth, increasing access for medically underserved populations, and providing race-
concordance patient-centered care encounters that improve patient outcomes. Practicing patient-
centered care within race-concordant healthcare relationships has shown higher respect
satisfaction among immigrant communities and effectively reduces disparities (Chu et al., 2021).
Race-Concordance and Patient-Centered Care
Race concordance between providers and patients can achieve treatment compliance and
better health outcomes. For example, a study of African American patients with high blood
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pressure revealed that patients treated by a different race are unlikely to trust their physician fully
and are prone to discontinue their blood pressure medication. Conversely, in provider/patient
race-concordant relationships, treatment adherence increases resulting in better blood pressure
control (Schoenthaler et al., 2014). Traylor et al. (2010) studied 131,277 adult diabetes patients
in northern California to determine the effect of patient and physician race/ethnicity on
cardiovascular disease medication adherence. The results of the study showed that:
Patients who are of the same racial or ethnic group as their physicians are more likely to
use needed health services are less likely to postpone or delay seeking care and report a
higher volume of use of health services. (Traylor et al., 2010, p. 1173)
Underrepresented patients choose physicians who mirror their ethnic background instead of
White patients. Increased diversity expands the options for minoritized patients and removes
obstacles to healthcare utilization (Smith et al., 2009). Gender and race concordance provides
life-saving benefits to patients. Research revealed that having a shared racial or gender
background between provider and patient in critical care settings decreases mortality through
more accessible facilitated communication and established trust, leading to treatment adherence
(Alsan et al., 2019). Research that examined race concordance among cardiovascular disease
(CVD) patients discovered that 46% African American, 49% Latino, 52% Asian, and 51%
Spanish-speaking patients were less likely to take all their CVD medications when compared to
White patients (Traylor et al., 2010). When researchers examined racial and linguistic
concordant patients with their physicians, 53% of African American and 51% of Spanish-
speaking patients adhered to all their CVD medications. Researchers concluded that race,
ethnicity, and language concordance could improve medication adherence and positively impact
health outcomes (Traylor et al., 2010). In another study, Alsan et al. (2019) launched research to
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assess whether physician race concordance for African American patients influenced their
willingness to receive preventative care or invasive testing in a clinical setting. During the study,
patients assigned to White and African American physicians revealed that communication
exchanges between African American physicians and patients were less restricted and more open
(Alsan et al., 2019). Findings revealed that patients spoke freely about health challenges and
were more considerate of preventive care and invasive testing. The association between race-
concordance provider/patient duos and willingness to comply with treatment, especially between
African American male physicians and male patients, was apparent (Alsan et al., 2019). Within
the same study, Black male patients were 18% more inclined to accept preventative care with a
Black physician than those assigned to a White physician. For invasive procedures, no pairings
with White doctors yielded compliance for invasive testing. Only Black male patients with Black
male doctors agreed to invasive testing, which increased diabetes and cholesterol screenings by
20% and 26% (Alsan et al., 2019).
Nazione et al. (2019) used an online survey to query 882 White and Black participants
with high cholesterol and blood pressure about their comfort and trust level with their physician.
The research documented similarities in the concordant Black group, which linked to the
likelihood that these patients were inclined to keep their race-concordant provider than those in
any other group surveyed. The evidence noted in the Cuevas et al. (2016) study that race
concordance was not mandatory for some African American patients; their main desire was to
have a competent physician who listened to them. However, one woman who preferred a same-
race provider stated that Black doctors would advocate for their patient’s care. The patient said,
“They are more compassionate. They always want to give you as much information and seem to
have empathy with you and everything” (p. 991). A qualitative research study that interviewed
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26 physicians (21 White, three Asian, and two Black) asked about their impressions of referring
Black patients to specialty care (Clark-Hitt et al., 2010). Within the study, a female doctor who
was White shared she did not refer Black patients to specialists because of their poor adherence
to managing their hypertension. Further, a White male physician agreed to share thoughts about
the non-compliance of some patients of color:
You wonder if it is because we as humans want people who look like us to get the care
that we would want. You know that there’s somehow a better identification of, “This
could be my grandfather, this could be my dad, or this could be.” Whereas someone who
is Black or Native American, or Somali, I just don’t quite, I don’t walk in their shoes as
easily. And, you know, who knows? Is there hard wiring there? I don’t know. I’d like to
believe that there isn’t. (Clark-Hitt et al., 2010, p. 393)
A patient-centered, culturally sensitive care (PC-CSHC) is an approach that embraces common
attributes shared among a community, language, race, ethnicity, and religion and acknowledges
these individuals’ unique attitudes, perspectives, and feelings during the healthcare encounter
(Tucker et al., 2015). Unlike the patient, providers who are not trained or represent a community
find it hard to display empathy towards diverse patients. As a result, providers engage in
‘othering’ racism by referencing patients as “the other,” implying their difference is a deficit
(Claeys et al., 2021). Researchers studied 81 over 55 Latinx, mostly male inpatient participants,
to determine if PC-CSHC affected their perception of care. Results indicated that providers with
higher cultural sensitivity are associated with favorable patient satisfaction, communication, and
collaborative care approach (Roncoroni et al., 2021). A shared decision-making process, an
attribute of PC-CSHC, illustrates the importance of the physician acknowledging the needs and
circumstances of their patients. Moreau et al. (2012) conducted four focus groups for a
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qualitative study that researched patients’ perceptions of decision-making. The study showed that
patient-centered care that included shared decision-making made patients feel respected,
acknowledged, and informed about their health. For example, a study patient declared, “It’s
important for the doctor to take the patient into account or the patient won’t comply with the
treatment” (p. 207). Communication, another critical component within patient-centered settings,
can reduce mortality risk in chronic conditions and misdiagnosis, help ease mental stress and
increase patient satisfaction (DHHS, 2019). Further literature disclosed that African American
patients experienced more patient-centered care when interacting with a racially aligned
physician (Schoenthaler et al., 2012). Black patients described higher collaboration, increased
recommendation adherence, better communication, more caring, and empathy in race-
concordance provider relationships (Schoenthaler et al., 2012).
Research evidence showed that racially concordant provider/patient relationships could
provide comfort, enhanced communication, trust, medical adherence, and access to care.
However, access to care for our vulnerable populations differs between rural and urban locations,
which vary in cultural and financial limitations that have compounded the availability of health
services and trained physicians (Douthit et al., 2015). Treating medically underserved
communities to decrease health disparity among marginalized people of color is another effort
where more diverse healthcare providers can be effective.
Access for the Medically Underserved
Meeting the healthcare and cultural needs of underserved communities through non-
restricted access can be attained through an ethnically diverse physician workforce. Those
underserved individuals living in poverty experience worse care access than households with
higher incomes (DHHS, 2019). In addition, Latinos (30%) and Blacks (15%) had the highest
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uninsured numbers in 2019 (Cohen et al., 2020). Although there are specialty differences in
practicing in underserved areas, physicians of African American, Native American, or Latino
physicians are motivated to practice in federally designated medically underserved areas
regardless of specialty (Xierali & Nivet, 2018). Primary care physicians of Native American
ethnicity will provide more care in rural parts of the United States than any other physician group
(Xierali & Nivet, 2018). Using CA Medical Board Physician Licensure Survey data, researchers
geocoded practice zip codes to medically underserved areas and primary care health professional
shortage areas. Results showed that 15% of White physicians were willing to practice in a
medically underserved area, whereas 28% of African American, 24% of Latino, 23% of Pacific
Islander, and 19% of Asian physicians chose to work in medically underserved and healthcare
shortage areas (Walker et al., 2012). This study indicates that underrepresented ethnic minorities
were more inclined to provide care in underserved communities than White physicians.
Ethnically diverse physicians can be essential in improving the overall healthcare of residents in
these communities (Walker et al., 2012).
The medically underserved are a racial and ethnic target group with high health disparity
caused by poverty, lack of insurance, and location. With current population projections, these
numbers will grow over time which can burden our healthcare systems if the number of
healthcare providers does not increase to match the demands of an expanding population (Colby
& Ortman, 2015). Therefore, the need for a healthcare system with more ethnically diverse
providers will grow along with the population numbers of minority groups.
Population Growth
Creating a more robust, ethnically diverse cadre of physician providers to address health
disparities has been a long-term goal for healthcare decision-makers (DHHS, 2019). Population
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projections for the United States show increased ethnic diversity over the next 4 decades (Colby
& Ortman, 2015). The U.S. Census Bureau forecast that in 2060, 32% of the projected
population will be non-White racial/ethnic minority, while the White population will decrease by
an estimated 19 million. Between 2017 and 2060, projected growth in the United States will
increase by 79 million people, bumping the estimated population to 404 million (Colby &
Ortman, 2015). According to the census study, the main driver of population trends in
international migration is high death and low birth rates among Whites, and in 2030 international
migration will outpace natural growth from U.S. births by adding 1.1 million people instead of
500,000 natural births by 2060 (Colby & Ortman, 2015). Life expectancy will also boost, with
almost a quarter of the population aged 65 or older living by 2060, which equates to 90 million
older-elderly adults in the United States (Colby & Ortman, 2015). White children will account
for less than half of 74 million children under 18 in the next 28 years, whereas ethnic minority
children will double their numbers (Colby & Ortman, 2015). The fastest-growing ethnic group is
people who are two or more races. This group will grow an estimated 200% by 2060, followed
by Asians, Latinos, and African Americans, who will slightly increase from 13.3% in 2016 to
13.8% in 2030 to 15% in 2060, with a 41% growth in 44 years (Colby & Ortman, 2015). Though
Whites will continue to be the most significant race, by 2045, they will no longer be the majority
(Vespa et al., 2018). Additionally, physician shortages are expected to increase in 10 years
throughout the United States (AAMC, 2019). This growing shortage will impact health
disparities and adversely influence patient-care outcomes. Today’s population is 60% White,
18% Latino, 12% African American, and 6% Asian. Still, physician percentages are 57% White,
6% Latino, 5% Black, and 17% Asian which does not reflect the current population, and
American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders are less than 1% of
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the population and physician representation (AAMC, 2019). The number of people of minority
ethnic groups will continue to grow. Projected growth for ethnic minorities is significant, with
nearly 10 million added to the population (AAMC, 2019). The need for services to meet growing
ethnically diverse patient groups is directly related to the importance of a physician workforce
reflective of the nation (Dall et al., 2020).
National Prevention, Health Promotion, and Public Health Council (2011) research
indicated determinant health factors of SES and the environment could be offset by increased
access for underserved populations and replaced by quality patient-centered care, preventative
resources, and information. Diversity in clinical medicine settings is gaining increasing support
to address problems of implicit bias, mistrust, substandard provider/patient communication,
health inequity, and patient-care outcomes (Clayborne et al., 2021). Increased representation of
ethnically diverse physician provider groups will provide the leverage needed to minimize the
many healthcare challenges of health disparities faced by minoritized patient groups.
Conclusion
Captured in the Institute of Medicine’s (Smedley et al., 2004) landmark research
emphasized the importance of the shortage of ethnic minority physicians in healthcare. This
seminal study concluded that diversity in healthcare is vital to meet the growing demands of our
national patient-care needs. It also states that a workforce of underrepresented physicians is
associated with access to care for ethnic minority patients, effective communication between
provider-patient, and an overall supportive, safe, and accessible experience for medical students
(Smedley et al., 2004). This study will reinforce these facts, provide a deeper exploration of the
individual journey for minoritized groups embarking on a medical career, and show how
representation is vital in minimizing the health disparity gap.
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Conceptual Framework
This study will utilize Bronfenbrenner’s (1979) ecology of human development
framework. Bronfenbrenner’s ecology of human development theory examines how the
environment impacts individual development. The framework uses interdependent settings
representing how external systems connect to the person. The individual setting establishes the
demographic profile, sex, age, health, and socioeconomic status of a person. Beyond the
individual, we move outward into the external environments of the ecological framework. The
microsystem, the outer layer closest to the individual setting, focuses on family, school, peers,
and intimate communities such as the church and neighborhood. Mesosystem serves as a layer
that bridges two settings: microsystem and exosystem. The mesosystem highlights the similar
components in these settings and their proximity to the individual. Exosystem also contains
neighbors and friends; however, these components are extensions of the structures found in the
mesosystem. For example, the exosystem includes an extension of friends or distant family
members instead of the individual’s intimate friend and familial relationships. Exosystem
expands the individual’s connection, including societal services and influencers, legal, social
welfare, and mass media. Macrosystem is a step beyond the exosystem and is the most outer
external setting, including cultural attitudes and ideology (Bronfenbrenner, 1979).
Bronfenbrenner’s ecological theory uses these settings as critical lenses to view and
examine how external forces can impact human development and influence the career journey of
ethnic minorities pursuing clinical medicine. In the context of the problem of practice, this study
will apply each setting to examine the underrepresentation of minority physicians and the impact
of the lack of ethnic diversity in addressing health disparities. Research questions will examine
ethnic minority underrepresentation using the appropriate ecological setting that aligns with the
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evidence collected through the study. Each research question (RQ) sequentially applies the
settings of Bronfenbrenner’s ecological system. Beginning with the three innermost individual,
microsystem, and mesosystem settings, RQ1 asks, ‘What factors influence minorities to choose a
career in clinical medicine?’ Research Question 1 probes the physician’s career journey as a
person of color, uncovering the influences of personal thought, community resources, and
societal challenges that impact career decision-making and attainment. The conceptual
framework’s setting of the individual represents personal thoughts on career choice options and
the internal perspectives that support or dissuade decision-making. An individual’s immediate
community of family, peers, church, and school are within the microsystem. This lens explores
how these close community components influence accessibility to resources needed for growth
and career preparation. The mesosystem links the immediate external environment and the
broader community influence of work, extended family, and friends. The application of this
setting examines how these areas also uniquely influence the journey of becoming a physician.
RQ2 queries, ‘How does representation of ethnic minorities in clinical medicine impact health
outcomes for minoritized patients?’ The key concepts covered with this inquiry are the distinct
perspectives of physicians of color and their impact on health disparities, experiences with
racially aligned patients, and the benefits of an ethnically diverse clinical workforce for
marginalized patients. Both exosystem and macrosystem settings are the most effective lens to
study how societal institutions, systems, and cultural ideologies influence the lack of
representation in healthcare and its impact on vulnerable patient populations.
All four lenses will examine the challenges and underpinnings of underrepresentation that
contribute to the lack of ethnic minorities in clinical medicine. The mesosystem and exosystem
will be the primary views used to examine the target population and stakeholders within the
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problem of practice. The final section of the study will focus on best practices and problem-
solving. The study will apply the ecological systems’ exosystem and macrosystem settings to
explore the impact and influence of diversifying the physician workforce. Figure 1 illustrates
Bronfenbrenner’s ecological systems’ environmental settings.

Figure 1
Ecological System

Note. Adapted from The Ecology of Human Development: Experiments by Nature and Design by
U. Bronfenbrenner, 1979, Harvard University Press. Copyright 1979 by The President and
Fellows of Harvard College.
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Motivational Framework
Self-efficacy is the motivational framework used to address the lack of ethnic minorities
in healthcare. Bandura (1997) defined self-efficacy as an individual’s belief in their skills to
control their behavior and external events to achieve a goal. Self-efficacious ideas are
fundamental to self-regulated motivation in determining whether one’s behavior will support or
obstruct goal attainment (Bandura, 2001). Self-efficacy is also an appropriate lens to examine
this problem of practice because individuals’ self-judgments about their abilities to perform
successfully or not reciprocally influence self-regulated behavior needed for goal achievement
(Elliot et al., 2017, Chapter 17). This approach will also provide a personal perspective of RQ1
that delves into why one chooses a career in clinical medicine. Using self-efficacy theory will
show how negative self-perceived beliefs can directly affect individual agency, motivation, and
self-regulation. Academic self-efficacy emerges as an element within the broader scope of
efficacy to further investigate the connection between self-advocacy and the school setting. Self-
efficacy contributes to effective academic achievement and growing interest in STEM.
Conversely, poor confidence or lack of self-efficacy can sabotage academic performance,
creating a barrier for ethnic minorities to enter STEM employment by influencing their choices
to pursue medicine and their determination to remain in STEM majors (MacPhee et al., 2013).
Lack of self-efficacy can undermine potential pursuits of a medical career and further deepen the
gap in ethnic minority representation in healthcare. Figure 2 illustrates Bandura’s five sources
that impact self-efficacy: performance experience, vicarious experience, social persuasion,
imaginal experience, and physical and emotional states within the underrepresentation of racially
diverse physicians in clinical medicine (Bandura, 1997, 2001).

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Figure 2
The Influencers on Self-Efficacy and Behavior

Summary
Ethnic minorities are disproportionately underrepresented in clinical medicine. Various
research studies have shown that social determinants of racism, inadequate education, mortality,
and lack of self-efficacy have challenged people of color and their pursuit of representation in
the sciences (Bandura, 1997; Byars-Winston et al., 2010; de Brey et al., 2019; Freeman et al.,
2016; Horowitz et al., 2019; Khan et al., 2018; Paradies et al., 2015). This lack of diversification
has shown to be detrimental to our healthcare systems, more importantly, our patients (Alcendor,
2020; Tai et al., 2021). Increased health disparities, poor access, mistrust, and de-personalized
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care further marginalize the most vulnerable groups (Bazargan et al., 2021; Bazargan et al.,
2022; CDC, 2021a; Cuevas et al., 2016; DHHS, 2019; Henke et al., 2015). The future projection
of growth shows the dire need for more ethnic diversity (AAMC, 2019; Colby & Ortman, 2015).
Black, Latino, Native American, and Pacific Islander providers are uniquely poised to address
the key factors that undermine the health of our growing diverse communities (Marrast et al.,
2014; Smedley et al., 2004). Ethnically diverse representation delivers care access in rural
communities, patient-centered encounters, cultural sensitivity, and effective communication
(Alsan et al., 2019; CDC, 2021b; Roncoroni et al., 2021; Traylor et al., 2010). Physicians of
color are inclined to work in urban, medically underserved areas, improve patient clinical
outcomes, and increase treatment adherence and medication compliance (Alsan et al., 2019;
Nazione et al., 2019; Schoenthaler et al., 2012; Walker et al., 2012). This research study will
contribute significantly to equitable access for marginalized communities, minimizing health
disparities and providing quality patient care. Disproportionately underrepresented in
professional STEM careers, African American males will be a significant benefactor of this
research (de Brey et al., 2019). Hopefully, the study will provide a different perspective and
potentially bolster confidence and efficacy to investigate the possibility of becoming a physician.
Based on the extensive problem of practice literature, this study will use narratives of active
physicians to address RQs about factors that persuaded their pursuit of medicine and how their
representation impacts health outcomes for patients of color. Data from these interviews and
corroboration with literature will offer insight into these compelling inquiries and provide best
practices for countering barriers that undermine ethnic provider representation in healthcare.

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Chapter Three: Methodology
This study aims to provide evidence of the need for ethnic minority physicians in U.S.
healthcare and demonstrate how physicians of color are uniquely equipped to reduce health
disparities within minoritized groups. The research detailed in Chapter Two identified the factors
contributing to underrepresentation and how the discrepancy of an ethnically diverse workforce
can adversely impact the health of marginalized groups of color. The study results will add to the
literature supporting physician providers’ diversification in addressing health disparities in ethnic
communities. This chapter begins with the RQs for the study. The conceptual framework of
Bronfenbrenner’s ecological systems (1979) and Bandura’s self-efficacy (1997, 2001)
motivational framework shown in Figure 1 and Figure 2 structure the RQs and key concepts
within the various ecological settings illustrating the individual and external components that
influence the study. The remaining chapter will describe the data collection method, researcher
positionality, data sources, credibility and trustworthiness, and ethics.
Research Questions
1. What factors influence minorities to choose a career in clinical medicine?
2. How does the representation of ethnic minorities in clinical medicine impact health
outcomes for minoritized patients?
Overview of Design
This qualitative research study will use interviews for data collection and analysis. Semi-
structured interviews with 10 questions (found in Appendix B) will be used to engage 12–20
ethnically diverse active physicians to learn about their experiences and perspectives. This group
is essential for the study because their knowledge, attitudes, and insights are critical to answering
the RQs. Patton (2002) stated those individuals who possess a point of view that is meaningful to
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the study and provides valuable information that can answer our RQs are the purpose of
qualitative interviewing. Through these physician narratives, we can learn what influenced them
to pursue medicine, discuss the barriers they encountered, and how they could navigate these
challenges successfully. In addition, physician practitioners can reflect and share their stories
about undergraduate and medical school, what essential factors helped them reach their goals,
and what pitfalls they experienced and observed that hindered them and fellow students.
Additionally, physicians can address the realities of the healthcare systems and the needs
of patients from the lens of a frontline physician. The literature will revisit in Chapter Five to
leverage existing information to address RQs without launching another data collection effort
(Robinson & Leonard, 2019). The semi-structured interviews will cover all RQs; RQ alignment
is in the appendix with questions.
Research Setting
CYMG Healthcare (pseudonym) is a large care provider located in California. The
organization employs over 80,000 administrative and clinical staff. Over 9,000 residents and
active physicians comprise the medical group and care for over 3 million patients. I will recruit
12–20 ethnically diverse physicians from CYMG Healthcare and other medical practices for the
interviews. Since I am an employee of CYMG Healthcare, I will have access to the target
population for the study. However, I am not operating in a managerial or supervisory capacity
and do not have any authority over the medical residents or physicians interviewed for the study.
The setting for interviews will be virtual using the Zoom platform. The interviewee and I will be
in separate physical locations using the camera and record feature to see each other with an
audio-only option if technical issues arise or the interviewee chooses not to be on camera.
Physicians may join from home or their practicing location. For CYMG physicians, their
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practicing site depends on their specialty, so the options will be the hospital or medical office
building.
The hospital settings are vast multi-level buildings that provide emergency, surgery, and
other invasive hospital in-patient services that require extended patient care. When not on
clinical duty, practicing physicians have offices to conduct administrative tasks for patient-care
management. Medical office buildings (MOBs) are smaller structures, usually less than five
floors, offering non-critical primary care services: internal medicine, women’s health, pediatrics,
and mental health. The MOBs have the same configuration for administrative work, offices for
practicing physicians. Hospitals operate on a 24-hour clock, whereas MOBs have standard 8- to
10-hour work schedules. The virtual space allows interview flexibility from a place of
convenience. Considering the highly impacted schedules of physicians, a virtual interview is the
best option and serves as an incentive to agree to the interview and minimizes the likelihood of
cancellation.
The Researcher
My role as a researcher for this study is to add to the existing literature that supports
ethnically diversifying the physician workforce to improve representation within healthcare and
decrease health disparities among minoritized groups. My positionality as a Black woman who
has a transformative worldview and has worked in healthcare administration for over 25 years
will directly influence my role as a researcher during the study. Based on the “Intersecting Axes
of Privilege, Domination, and Oppression” wheel, I am privileged but oppressed (Morgan,
2018). However, as a Black female navigating healthcare as a patient, I am part of the larger
Black community that contends with chronic conditions, implicit bias in the exam room, and a
deep mistrust of healthcare due to historical atrocities against Black people. Regardless of my
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privilege attributes in higher education, able-bodied, heterosexual, English-speaking person, my
oppressed positionality counters the privilege in the eyes of healthcare. Therefore, a
transformative worldview serves as the paradigm of inquiry for the study. This worldview looks
at communities marginalized and alienated within society due to discriminatory practices based
on race, gender, sexuality, and socioeconomic status (Creswell & Creswell, 2017).
Axiology is the study of values. In the research context, our values impact and shape how
we pursue inquiry and guide the ethical criteria we use to balance, judge, engage, evaluate, and
conduct our study (Lyon, 2017). In addition to transformative, I align with the interpretivist
worldview, reflecting my axiological approach. The value of lived experiences, historical
influence, honoring the voice, and the interpretations of those silenced and affording them
agency are vital to me and reflect my values and passion (Saunders et al., 2007). Ontology is a
philosophy that examines human beings and their state of existence as individuals or part of a
societal group (Lyon, 2017). In my study, the ontological lens will look at the external structures
of systems and institutions that have imposed barriers, preventing the elevation of ethnic
minorities in healthcare.
Furthermore, I will examine the evaluation of how these same factors adversely affect
self-efficacy within the study. Finally, epistemology is the “nature of knowing” (Hinga, 2021).
For this study, the holders of knowledge will be the data solicited from empirical studies that
focus on the external societal and institutional elements that contribute to this problem of
practice and qualitative data from participants through conversations with myself as the
researcher.
My experience as a Black woman in the United States will enable me to connect with
physicians of color and reveal my partiality, specifically toward the lack of African American
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physicians. African American physicians are the second-lowest represented ethnic group in
healthcare, totaling only 5% of the nation’s practicing doctors, and are the largest
underrepresented group in clinical medicine (AAMC, 2019). My bias may cause me to lean more
toward uncovering the barriers contributing to African American underrepresentation instead of
the lack of racially diverse representation. My inclusion in an ethnic community with a shared
historical American experience of human trafficking and enslavement may limit my
understanding and awareness of the immigrant experience and other factors unique to non-
African American minority groups. Additionally, my gender might be a factor with male
physicians. Areas exclusive to the male experience could present a dilemma during my study.
The perception that I may not grasp or perceive the challenges and barriers that male minority
physicians face could deter some participants from fully disclosing their experiences. Also,
working with leaders in the healthcare community, for example, the AAMC, primarily White
males, can pose a similar issue. My plan to mitigate these potential problems will rely on my
previous and current experience with both groups. To mitigate positionality influences, I plan to
use my reflexivity approach to validate my data. By fully disclosing my positionality, the
potential impact of my perception, biases, and worldview may have on the research will provide
transparency. Another strategy is member checks, allowing participants to review portions of the
research study and finally use detailed, thick, illustrative descriptions of the setting, people, and
situation (Merriam & Tisdell, 2015). Additionally, my familial and professional relationships
with other minority groups will help me navigate some of the blind spots that may arise due to
my limited knowledge of different cultures, experiences, and gender. For my corporate
encounters, I can leverage my internal medical group relationships, reputation for producing
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high-quality clinical programming, and long-established partnerships with professional
healthcare societies to access data relevant to the research study.
Data Sources
The primary data source for the study will be interviews, and government and institution
report as secondary data. Through organizational contacts, medical associations, and professional
minority ethnic groups, I will solicit 12–20 active physician candidates as interview participants.
Interview invitations will be sent, scheduled, and conducted over 120 days. After the interviews,
secondary reports documenting existing statistical medical data based on racial ethnicity will be
pulled from the CDC and the AAMC.
Interviews
Applying the conceptual and motivational frameworks for the study, interviews will
explore individual, external, and self-efficacy factors that shaped the participant’s journey to
becoming a doctor and the impact physicians of color have on patient care for minoritized
groups. Each active physician’s thoughts, influences, challenges, resources, and encounters
working within the healthcare system and with patients will provide revealing narratives to
inform the underrepresentation of ethnic minority physicians. These interviews fill in the gaps
that cannot be observed. Their reflective insight, current knowledge, and lived experiences are
meaningful data that can be collected when other options are not feasible (Merriam & Tisdell,
2015).
Participants
Purposeful selection is the sampling method I plan to use to identify interview
participants. Maxwell (2013) stated that intentional selection provides the researcher with people
with specific knowledge, experience, and expertise to answer RQs effectively. The AAMC’s
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(2020) definition of an ethnic minority or underrepresented minority is Black (i.e., African
American, Caribbean American), Latinx American (i.e., Mexican American, Puerto Rican), and
Native American (i.e., American Indian, Alaska Native, and Native Hawaiian). I will use this
definition to identify and create a demographic profile of the target audience for this study.
Purposive sampling of the target audience will yield relevant information not obtained elsewhere
to address the study’s RQs adequately. I plan to use my physician leadership contact(s) within
my organization and medical professional societies to provide a list of potential ethnically
diverse active physicians to interview. Invitations will be disbursed via email to secure 12–20
participants.
Instrumentation
This study will utilize a semi-structured interview protocol (see Appendix B). Merriam
and Tisdell (2015) described semi-structured as interviews that use structured, flexible questions
and can be re-ordered and seek specific data from interviewees that address the study’s RQs. The
semi-structured approach is fluid, allowing the opportunity to ask probing questions to gain
further insight into the topic and yield rich data (Burkholder et al., 2019). Based on my
conceptual and motivational framework, the interview protocol will have 10 questions in three
areas. The questions will include the personal journey that led to their decision to pursue
medicine, their perspectives on the factors that contribute to underrepresentation in healthcare,
and the impact on the health disparities experienced by minority patients. Each section has five
questions designed to answer the associated RQ. Along with the questions, alignment to RQs is
in Appendix B. The appropriate conceptual and motivational framework lens is applied to each
area based on the represented individual or external environmental factors (see Appendix B).
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Data Collection Procedures
After the interview is secured with an affirmative response to my invitation email, each
confirmed interviewee will receive a study information sheet (see Appendix B). The study sheet
will emphasize that the interview is voluntary, confidential, and can be stopped anytime.
Additional study sheet components include the IRB approval number, my research role
description, the study of interest, the type of study, and the three sections of topics the interview
questions will cover. Also included in the study information sheet is an outline of the interview
process that will cover essential interview logistical information. Specifically, participants will
be informed that the interview will be an hour, strictly confidential, with the assurance that none
of the data will be personally attributed to the participant. The interviews will be conducted,
recorded, and transcribed synchronously via my Zoom meeting account. A backup recording
device will be on hand in case of technical difficulties with Zoom. All data will be stored on a
password-protected computer and destroyed within a year after the completed study. There are
several reasons why I chose an online interviewing method to gather participant data. First,
considering the ongoing pandemic, in-person interviewing is not feasible, and Zoom or another
online meeting platform is an acceptable option to ensure safety. The target audience for this
study is busy with limited time; online interviewing allows participants to join using an internet-
ready device from any location. Most online meeting applications do have a transcription feature,
including Zoom. Accessing the transcribed recording within minutes after the interview has
concluded is a significant time and cost savings. Merriam and Tisdell (2015) cautioned about
potential technical difficulties and lack of technological knowledge as potential risks that can
interfere with the interview. Though valid concerns, the target audience for this study is
technically savvy and uses online meeting technology frequently. The pandemic has prompted a
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significant increase in learning technology, elevating skill levels to proficiency. Also, most
physicians participating from the hospital, clinic, or home have sophisticated internet capability
due to the expansion of patient video visits.
Data Analysis
Interview data will be analyzed as it is being collected. Merriam and Tisdell (2015) stated
that collection and analysis should coincide to avoid insurmountable work that could overburden
the researcher and undermine the research findings. Each Zoom recorded interview will be
transcribed using the application’s transcription function. The interview questions and answers
list will be organized by their associated RQ and conceptual and motivational framework setting.
Critical concepts for each RQ will serve as themes, and those themes will code interview
question responses within a particular RQ. After each interview, the components of the study,
purpose, conceptual and motivational frameworks, inquiry worldview, key concepts, and RQ are
reviewed. Next, the interview transcript will be reviewed, and reflection and observation notes
will be documented. Afterward, all the study components and the interview findings are
compared to see what is aligned, missing, and unexpected. Three phases of coding will be
applied: open, axial, and selective coding (Merriam & Tisdell, 2015). In the early stages of the
study, open coding will be used to tag anything applicable to the study. After the first three
interviews, axial coding begins with creating categories saved in an Excel spreadsheet and then
used to help inform the remaining interviews. The last phase of selective coding starts, where
core categories are developed for data compilation, and the spreadsheet is updated to reflect
these core categories. Notes will be made during the interview to compare with the transcript and
incorporated into the Excel spreadsheet along with the axial and selective coding. Using an
inductive and comparative approach, these steps are repeated to formulate categories from the
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coding and are adjusted until a consistent pattern of categories emerges. This method of constant
comparative analysis between categories to build concepts through inductive reasoning is called
grounded theory (Merriam & Tisdell, 2015).
Credibility and Trustworthiness
Merriam and Tisdell (2015) offered multiple strategies researchers can use to confirm
research credibility and trustworthiness, triangulation, member checks, adequate engagement,
researcher’s position or reflexivity, and peer review. For my study, triangulation, maximum
variation, and reflexivity are three strategies that will be used. Data collected by government
agencies and medical organizations will be used as secondary data to triangulate the findings of
primary data collected through interviews. Large projects supported by well-funded
organizations produce highly reputable results by utilizing well-trained staff, reliable data
collection methodologies, large participant populations, and scientific sampling (Boslaugh,
2010). Existing data reports accessed from the CDC and the AAMC websites will be selected
based on the RQs, key concepts, and interview questions.
Additionally, AAMC will accept requests for a customized report based on research
parameters. If the request is approved, the customized report is created and provided for use in
their study. The organization that I work for is a healthcare system in California. Specific data
demographic sets for active physicians are available based on my role in the organization. The
organization data could be used as a case sample to compare the government and institution data
and the interview data. The following strategy is maximum variation. To achieve optimal
variation, purposive sampling will be used to source a range of ethnic groups based on the
AAMC (2020) definition of racial ethnicity and the length of time working as an active physician
53

in clinical medicine. Finally, my position or reflexivity will be documented to describe how my
worldview perspective and bias may impact the study.
Ethics
Merriam and Tisdell (2015) stated that valid and reliable research depend on
methodological rigor and the ethical credibility of the principal investigator. Based on university
guidelines, my study is minimal risk, so a study information sheet, which does not require a
signature, will serve as my process for participant consent. The information will outline the
following; the purpose of the study, the role of the participant, any incentives that may be
offered, the rights of the participant (participation is voluntary and withdrawal from the study is
permitted at any time), how the information will be stored, explanation of any risk involved, and
complete confidentiality is guaranteed (see Appendix B).
I do not hold a role of authority within these relationships, so there is no risk of an
unbalanced power dynamic or threat of coercion for any research participant. My part is not to
force but to respect all participants and honor their voices authentically without judgment. For
participants, especially African Americans, the assumption is that our status as ethnic minorities
and historical connection would provide comfort and trust.
The organizational leaders, primarily White men, will consider my director position and
years within the organization as a sign of trustworthiness. However, for both groups, my female
gender could be a factor and potentially prohibit full transparency from the males in the study
group. Nevertheless, the strength of my reputation and familiarity within the organization will
help assuage my colleagues’ hesitancy. Therefore, following the steps of the university and my
organization’s IRB process, my proposal will be submitted for review and approved before
participant outreach begins.
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Chapter Four: Findings
Currently, limited research investigates why people of color pursue medicine.
Discovering career pursuit indicators for people of color provides essential data that helps inform
how to support the growth of racial and ethnic-diverse representation in clinical medicine. The
focus of the study was to determine the factors that influence minorities’ decision to pursue a
career in clinical medicine and their commitment to closing the health disparity gap within
minority groups. The following RQs were used to guide the study.
Research Questions
1. What factors influence ethnic minorities to choose a career in clinical medicine?
2. How does the representation of ethnic minorities in clinical medicine impact health
outcomes for minoritized patients?
The data collected was organized and analyzed to address the RQs for this study. First, I
overview the emerging themes and outline categories for each RQ. These themes include
challenges and barriers, supportive resources, influences, career indicators, and minoritized
patient benefits and challenges. Data examples and interview quotes are provided as evidence to
support each theme and category. I will conclude by reviewing the RQs and summarizing the
main themes and categories discussed in this chapter.
Description of Participants
Twelve active physicians representing multiple clinical specialty areas and various racial,
ethnic, and cultural identities comprised my study participants. Table 1 shows the distribution of
study participants by first name (pseudonym), ethnicity, and dominant career indicators.

55

Table 1
Description of Participants
Participant
pseudonym
Ethnicity/race Specialty Dominant career indicators
Morris Latino Pediatrics Desire to help others
Extra-curricular activities and
persons of color associations
Parents/family-college educated
Stan Latino-White Oncology/hematology Desire to help others
Parents/family
Lola Black and Filipino OB/GYN Ethnic representation
Interest in STEM
Parents/family
Greg Filipino Primary care Desire to help others
Ethnic representation
Parents/family-culture
Natasha Nigerian American Emergency medicine Desire to help others
Ethnic representation
High self-esteem
Marie African American Dermatology Desire to help others
Interest in STEM
K–12 STEM education
Carol Afro-Caribbean
(Belize)
Primary care Desire to help others
Parents/family
Patty African American OB/GYN Desire to help others
High self-esteem
K–12 STEM education
Vicki African American OB/GYN Desire to help others
Ethnic Representation
HBCU undergraduate and
medical school
Todd Nigerian American Orthopedic surgeon Desire to help others
Extra-Curricular Activities and
Persons of Color Associations
HBCU undergraduate and
medical school
Phyllis African American Pediatrics Ethnic Representation
HBCU undergraduate and
medical school
High self-esteem
Theresa African American Internal medicine Desire to help others
Ethnic Representation
HBCU undergraduate and
medical school
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Research Question 1
Research Question 1 asked: What factors influence ethnic minorities to choose a career in
clinical medicine? For this RQ, I explored participants’ challenges and barriers, supportive
resources, influences, and career indicators influencing their career decision-making. Overall, 18
categories associated with these themes were identified, analyzed, and discussed. In addition,
participant interviews provided rich data outlining the factors that impacted ethnic minorities to
pursue their medical careers.
Challenges and Barriers
Instances that hinder or undermine success in attaining a desired goal are considered a
challenge or a barrier. Barriers that participants commonly mentioned were discrimination and
prejudice, lack of STEM education, lack of mentorship, lack of ethnic representation, and lack of
financial resources. Participants described their experiences when confronted by these
difficulties early in their medical journey.
Discrimination and Prejudice
Discrimination and prejudice include opposing, harmful, and exclusionary behavior
toward an individual or group based on identities of race, ethnicity, gender, religion, and sexual
orientation (Paradies et al., 2015). Five out of 12 participants quoted instances of discrimination
and prejudice that impacted their professional journey. Though the focus of the study is centered
around racial, ethnic, and cultural underrepresentation, identities of sexual orientation and gender
emerged in the findings as additional sources of challenges. Stan, an ethnically Latino and
racially White physician with 6 years of clinical practice, shared that microaggressions, an
indirect and subtle form of discrimination, were directed toward his sexual orientation. He stated
that as a resident, his chief, during clinical rounds, commented on gay marriage:
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There have been microaggressions that you hear. Like one of my chiefs, she came into
my office and said, “Well, you know I’m okay with gay marriage.” I’m like, “Well, how?
Why is that something that you need to tell me?” You don’t have to tell me that you’re
okay with me.
Stan commented that some patients also made identity-based references: “With patients, it’s
something that I continue to navigate every day for sure. My ethnicity, my sexual orientation,
and my country of origin are things that I navigate every day.” These remarks made by medical
staff and patients indicate that sometimes judgments are made based on observable
characteristics that signal the person is dissimilar from the societal norm. This quote suggests
that Stan feels on guard, and these microaggressions constantly remind him that he is different
despite his medical degree and qualifications.
Lola, a Filipino and Black mixed heritage physician who has worked in women’s health
for over 10 years, shared a similar experience of discrimination and prejudice. She said, “I
remember talking to my med school advisor when I was getting to the med school application
process, and he said, ‘Oh, you’ll have no problem getting into med school; you know you’re a
woman.’” In Lola’s example, her gender was the target of the microaggression. The comment
implies that because of her gender, Lola is fulfilling a quota for medical school admittance.
Without being a woman, she could not get into medical school on her merit alone. Though racial
and ethnic representation is the primary focus of the study, in these narratives, both Stan and
Lola emphasized that sexual orientation, country of origin, and gender can also trigger
microaggressions.
Another challenge observed by participants is the poor perception of affirmative action.
Affirmative action is a program that provides equitable opportunities for marginalized and
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underrepresented minorities. However, many view the program as an effort to aid groups
perceived as intellectually inferior. Carol, an Afro-Caribbean immigrant from Belize with 20
years of practicing medicine, described the impressions she would hear about affirmative action.
She shared,
People always think that, oh, you know, minorities get a break because of affirmative
action. That’s such BS. That’s just one tiny portion of it. You’re competing with people,
you know. Your grades have to be stellar. Your extra-curricular activities have to be
stellar.
Non-minority individuals with a prejudicial point of view about affirmative action minimized
Carol. This perceived behavior frustrated Carol and suggests she was resentful because the
reality is that individuals of color work hard and produce results comparable to White
individuals. Another example Lola shared from a White male college friend illustrates this point.
According to Lola, he said, “Oh, it’s easier for people of color or minorities to get into med
school now than White males.” These findings implied that non-minorities believe that programs
like affirmative action are needed for persons of color because they perceive their academics and
experience do not meet the requirements for a medical career. The assumption is that
underrepresented minority performance is inadequate. The data suggest that participants believe
academic performance and extra-curricular requirements must be exceptional regardless of
affirmative action or other perceived special treatment.
Another challenge participants share is that people with historically oppressed identities
feel they do not belong in specific neighborhoods, restaurants, or professions. Natasha, an
emergency medicine physician practicing in California, spoke about prejudiced statements she
heard from non-ethnic minorities as a pre-med student in a predominately White institution
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(PWI): “People will give you subtle reminders now and again that maybe you are pursuing
something that doesn’t really fit with who you are.” Natasha’s observation indicated that non-
ethnic minorities view persons of color unsuitable for certain professions. The pervasiveness of
the discrimination Natasha experienced was unsettling, indicating that her academic achievement
and intellect were insufficient to overcome racism. She concluded her thoughts about the
persistent prejudicial thinking towards African Americans that seems most prevalent in the
United States. Natasha stated, “I think as a Black American in this country from a very, very
early age, you get sort of inputs that maybe you might be different.” These messages received by
Natasha showed how her life’s course was pre-determined by standards designed to exclude her
based on racial and ethnic identity.
The challenges and barriers of discrimination and prejudice based on stereotypes are
examples of implicit or unconscious bias. Stereotypes are rigid one-dimensional viewpoints of a
particular person or group. Those that hold stereotypical beliefs tend to marginalize individuals
based on their identity. For example, Todd, a Nigerian American who works as an orthopedic
surgeon, recalled how his White colleagues referred to him using a racially motivated reference.
He shared, “I remember one of my nicknames during my time in training; my co-resident
buddies would call me the thug whisperer.” This comment was in response to Todd treating
primarily African American men in their orthopedic group practice, whom his co-residents called
“thugs.” This reference perpetuated the stereotype that African American men are brutes or
criminals. By making this association, Todd’s peers inferred that because he is African
American, he can relate not only by shared ethnicity but also by understanding perceived illicit
behavior. Colleagues are not the only sources of implicit or unconscious bias that physicians of
color face. Patients also can reflect these attitudes. For example, Todd recalled his patient
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experience while in training and how White patients would question his decision-making
capabilities, whereas patients of color would not create the same challenge. The patient
interactions Todd described are cues that remind him he is judged based on stereotypical
generalizations instead of his medical expertise.
The research findings unveiled a variety of encounters that showed discrimination based
on race, gender, and sexual orientation from those in authority, peers, and patients. In addition,
they discussed numerous experiences with prejudicial assumptions in the form of
microaggressions and implicit or unconscious biases. In addition to discrimination and prejudice,
findings disclosed that minimal exposure to STEM education is another barrier persons of color
confront in their early stages of medical career development.
Lack of Focus on STEM Education
A lack of focus on STEM education influenced physicians’ career choices. Before
entering an undergraduate program, research data showed that five out of 12 participants
experienced challenges in their early academic careers. Lola shared her thoughts on where she
was academically compared to her White peers:
I feel like it wasn’t until med school that I figured out that a lot of these kids are coming
in, having done all this STEM-specific programming, and like standardized tests training,
all that stuff like I had no idea—just figuring out that kids were like sharing test banks
and accessing certain things. So, I feel like STEM specifically wasn’t something I was
exposed to in a very intentional way.
The lack of opportunities for early STEM exposure and standardized test prep made Lola feel
excluded and that the coursework was not intended for her. This experience reinforced the idea
of exclusion and potentially left Lola disadvantaged, needing to work extra hard to address the
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gap between herself and her White peers. Carol shared a different perspective about her
educational experience:
So, I went to an all-girls school, and it was preparing you to be a wife, like cooking. We
had biology and chemistry, but you know, most of the girls preferred to be wives, believe
it or not. Wow, I didn’t even know what STEM was.
Carol’s school experience reflected the values of her country Belize; however, she chose to defy
cultural norms and pursue a career typically reserved for men. This empowerment prompted her
to seek avenues to expand her knowledge about the sciences. As a result, Lola, and Carol
experienced exclusion, where they had to rely on their motivation to obtain advanced STEM
education to prepare for a medical career.
Vicki, an African American obstetrician-gynecologist who has been a practicing
physician for 20 years, reflected on a negative encounter with an undergraduate professor. She
called him “Professor W,” reminding her of how unsupportive teachers during the K–12 years
can diminish a student’s willingness to choose a medical career. Vicki shared,
I know that same Professor W is Teacher W earlier in life in grammar school, middle
school, and high school, and that creates a narrative in the minds of young children so
that they don’t necessarily get a chance to develop that confidence that I have. And so, if
you lack confidence, by the time you get to college and Professor W is reinforcing what
teachers have said your whole life, then you will opt out of pursuing certain career paths.
The example Vicki shared showed how poor assessments of children in early primary education
can continue throughout their academic career and impact how they choose an occupational path.
The story implied that some students who do not have options to counter teacher or professor’s
fixed mindsets could change their career trajectory. Vicki demonstrated how her confidence
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could offset the urge not to pursue medicine. Fellow volunteer participants also showed
resilience despite being in an unsupportive academic environment. Theresa, an African
American practicing adult and family medicine physician for 33 years, reflected on her
undergraduate experience at a PWI. She shared, “Just being African American at Yale was hard.
You leave feeling like you survive there. You belong there just like anybody else, even though
that’s not what it felt like when you’re going through.” The overall outcome showed that these
physicians of color persevered despite systemic exclusion in their educational experiences.
Participants described their limited exposure to STEM, before medical school, as a
challenge, like the lack of mentorship they identified. Not having guidance or direction-imposed
barriers to successful medical training progress can complicate the road to a physician career.
Knowledgeable support and leadership can provide critical information to fill gaps marginalized
groups might not otherwise know.
Lack of Mentorship
Lack of mentorship was another factor that impacted career decision-making. In this case,
a mentor is knowledgeable about becoming a physician and available to give advice. Typically,
in the medical field, mentors could be instructors, active physicians, or peers in pre-med or
medical school. The study documented various examples of navigating the process of becoming
a physician without direction or a guide. A lack of mentorship can produce confusion by not
knowing the steps in the medical career process. Participants shared that they were the first in
their families to embark on this journey. Six out of the 12 participants indicated that no roadmap
was available, and participants had to learn how to address this barrier independently.
Patty, an 18-year veteran in obstetrics and gynecology, articulated the challenge of being
the first in her close community to pursue medicine: “I am the only physician in my family, so
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there definitely was not a blueprint for that.” Marie, who has practiced for 20 years on the West
Coast, described her experience as a first-generation physician and the obstacles she endured not
having a mentor:
I, like a lot of Black physicians, am the first physician in my family, so I had to rely on a
lot of information from others, just really understanding how to chart that path to
medicine. That was extremely challenging because I think that with my children, I can
help to direct them and be very strategic, whereas I didn’t necessarily have those types of
resources available to me.
Like Patty and Marie, 50% of the study participants shared similar sentiments about not having a
mentor or guide during their journey. Vicki stated, “There were no physicians to really help me
to ask questions or to really guide and support me.” Carol commented, “I didn’t really have
anybody in my life who was a physician or who had even been to college.” Marie shared how
she witnessed individuals become disillusioned and decide not to pursue medicine because of a
lack of mentorship. She shared,
Some of the times people are told that you need a certain GPA to get into medical school,
and there’s a lot of people who are high achievers that, oh my God, and if they don’t
make that certain GPA, then they decide not to apply to medical school when they were
excellent candidates to go to medical school. There’s all these other people that are out
there that are being discouraged and not given the resources; it really breaks my heart
because I just feel like a lot of their dreams are taken away from them. It’s not because
they can’t make it through it, but it’s just that they’re not getting the right advice.
Moving through these steps as a person of color without direction or being the first in the family
to pursue medicine was difficult. These data outcomes showed that not having mentorship is a
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significant challenge for first-generation physicians of color. Unfortunately, this can cause
unnecessary delays or abandonment of the profession. Similarly, the lack of ethnic representation
can have similar results. Without comparable identities reflected in the health professions can
limit the aspirations of individuals of color who desire to pursue medicine.
Lack of Ethnic Representation
The lack of representation is another challenge that participants identified. Ethnic models
in occupations where racial and ethnic diversity is rare, provide hope to people from diverse
populations who want to attain a particular career goal. Conversely, underrepresentation can
challenge individuals of color to visualize their presence in that field. In clinical medicine, where
representation is minimal for persons of color, success is complicated or impossible if there is no
example to emulate. Morris, a Latino pediatrician with 20 years of experience, expressed that the
lack of visibility created a mindset that a medical career is only for some. As a result, he stated,
“There are people with tremendous talent and potential who get turned off to clinical medicine as
a career choice. Just based on feeling like it’s only a realistic option for a small number of
privileged people.” Morris’s thoughts implied that seeing ethnically diverse physicians
communicates to emerging physicians that it is possible to achieve and be accepted. Conversely,
no representation reinforces the notion that clinical medicine is not an option if you identify as a
person of color.
Lola shared her sentiments about underrepresentation and its impact on her perception.
She commented, “Maybe I had one Black physician growing up, but it wasn’t something I
thought was normal to me.” She continued her thoughts about leadership and how a lack of
representation can restrict diversity. Lola said, “A lot of people in leadership reflect the people
who are going to medical school, you know, 30-plus years ago, at that time, it was predominantly
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male and a lot less ethnically diverse.” The implication is that healthcare leaders contribute to the
lack of diversity because they tend to hire individuals who are predominately White males like
them. This practice reduces the amount of variety in the physician pipeline.
Sexual orientation was another characteristic that Greg, a Filipino adult and family
medicine physician, discussed in his interview. In addition to being the only brown person in his
meeting with leadership, he shared, “And then being gay, that added in another kind of layer, to
that otherness being in that room.” These findings showed that sexual orientation is also a
diversity factor not widely reflected in the physician population. In Greg’s situation, the
intersectionality of his ethnicity and being gay reinforced the feeling of isolation and being an
outsider among White leadership. However, minimal or no representation can indicate that one
does not belong. These challenges and barriers noted by the study participants left them to
manage their journey without a tangible representative.
Additionally, the financial resources required to fund medical training posed a challenge
for persons of color. The constraint of limited funds threatened their ability to move forward with
their training. These obstacles presented complications that impacted the career journey.
Financial Resources
The lack of financial resources is a challenge and barrier participants described. Minimal
financial options can cause roadblocks along the journey to becoming a doctor. The data
collected found that 42% (five out of 12) of participants needed financial support. Marie
expressed how financial limitations were a challenge, “I actually saw me not being able to
achieve my career more so because of limited resources. I was just concerned about having
resources and funds available to me for the long haul.” Marie showed that some physicians found
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the lack of finances a threat to completing their education and training. Marie felt the possibility
of not achieving her career goal could prohibit her from becoming a doctor.
Carol shared a similar challenge and offered how she overcame the minimal availability
of resources, “I went through undergrad paying on my own. And then I had to work. And then I
went to graduate school and did public health as a microbiologist.” In her response, she also
acknowledged the impact on racial and ethnic minorities. Carol surmised, “So, I think for a lot of
people of color, if they knew somebody who’s been through that journey and can tell them about
pitfalls and show them the way, it would be a big help.” Limited funds were a genuine concern
for both Marie and Carol. The implications of worry and taking on additional work to meet
expenses can add stress and pressure, which can complicate the process for medical students of
color.
Theresa lent her voice to describe the significance of the financial hurdles she
encountered: “We had a lot of financial challenges growing up and just the possibilities of how
nothing was a given at all. And so, I always knew that I might take a different path at any
moment.” The threat of not continuing the studies and training required for practicing medicine
cautioned Theresa that leaving the profession could be her reality. Feeling like a failure and
being dissatisfied with changing their career plans are the risks that persons of color face when
financial obstacles are part of the journey. Additional participants shared that they found support
through student loan programs and scholarships to address financial barriers. These areas of
assistance provided temporary relief from the economic challenges of becoming a doctor.
However, the obligation of finances associated with a medical career is a significant undertaking
that can impact individuals long-term.
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Several challenges and barriers influenced career choice. For example, discrimination and
prejudice, lack of focus on STEM education, lack of mentorship, lack of representation, and lack
of financial resources appeared in over 50% of the data collected. These challenges are evidence
that these factors contribute to the complications persons of color confront in choosing a medical
career.
To overcome these challenges and barriers, the emerging theme of supportive resources
offered factors that provided helpful assistance for persons of color. The study outcomes include
multiple supporting resource categories that address obstacles that potentially prohibit promising
individuals of color from pursuing medical careers. In addition, findings outline specific
supportive resources that positively impacted career choice and persuaded respondents to
continue their journey of becoming a physician.
Supportive Resources
A significant theme that influenced participants’ career decision-making was supportive
resources, which are provisions that supply a means to meet a need (Merriam-Webster, n.d.-d).
Supportive resources indicate that assistance is provided with reassurance, care, and
encouragement to fulfill a necessity. Participants described supporting resource categories such
as parents and family, STEM education, extra-curricular activities and persons of color
associations, mentorship, and community.
Parents and Family
Six of the 12 study volunteers stated that parents and close family provided considerable
resources that supported their career plans. Stan spoke about his parents and family:
I was privileged and lucky that my family had the resources to get me a good education
from the very beginning to get me into a university to help me. They could financially
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support me when I was moving to the U.S. From very early on, they [parents] pushed
education as something that was very important for my siblings’ career and my career.
The education and financial support Stan received from his parents were pivotal in launching his
residency training and practice in the United States. Without his parents, Stan may have stayed in
Mexico to practice medicine and not realized his goal of providing care to marginalized
communities in the United States. Theresa described how her home foundation, designed by her
parents, set her on a medical career path:
[I] had all kinds of things, you know, microscopes and, you know, all kinds of exposure
to science, watching documentaries on TV, so very exposed to kind of the magic of
science and also the magic of the human body. But you know, the perseverance that my
parents had and knowing that I was worth that effort and knowing how to do it, I mean, I
was fortunate; they knew how to advocate even though they didn’t have the money. I
think that’s a privilege a lot of people don’t have. That was very helpful.
Theresa’s example showed how parents could create an environment to foster an interest or
support a desire that can positively influence an outcome, implying that Theresa’s parents’
efforts significantly impacted her medical career choice. Stan, Theresa, and the additional 30%
of the participants acknowledged the essential support of their parents and close family in
helping them achieve their goal of pursuing medicine.
STEM Education
Another supportive resource was exposure to STEM courses. Seven out of the 12
participants remarked favorably about their educational experiences. Morris, Natasha, Marie, and
Stan’s data emphasized that high school STEM classes and participation in entry-level college
science courses positively impacted their academic achievement and preparation for advanced
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science coursework. This outcome suggests that high school and college participation in STEM
curricula can influence career decisions in the medical sciences. Additional findings from Greg
indicated how the quality of the schools within a highly funded school district had a positive
effect on his education:
I’m a product of good public schools in Orange County. That helped me build a
foundation. Then high school, of course, there was physics, chemistry, and biology AP
that was part of the placement program. So, pretty early on, consistent throughout my
public-school journey, which was well-resourced.
Greg’s experience inferred that fully funded schools within specific communities offer extensive
education, including STEM programs and AP-level classes. These supportive resources can
equip students of color to achieve and compete on par with non-ethnic groups. However, this can
be challenging for those who do not live in areas that can offer quality science and math
curriculum. Patty commented that she also spent her K–12 academic years in well-resourced
private schools where STEM was the standard curriculum. She revealed the impact of same-
gender education as a positive resource that influenced her self-efficacy. She stated,
I went to an all-girls school, and I tell people 100% that is part of the reason I was raised
with so much confidence and to have all those resources, all that support, and none of the
BS from the boys at the same time really made a big difference.
Patty’s story suggests that same-gender educational experiences empowered girls, supported
their voice, and built confidence which was helpful in their STEM academic achievement.
Confidence aids in their ability to succeed beyond high school and perform well in higher
education. The research findings included Todd’s undergraduate work as a significant supportive
resource for MCAT test preparation, a requirement for medical school entry. Todd shared,
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I definitely took advantage of study courses for the MCAT, which was offered in my
undergrad at Xavier University of Louisiana. That was a standard part of our curriculum,
to do an MCAT prep course.
This finding implied that Todd felt equipped to apply to medical schools with these additional
classes. It also suggests that Todd had confidence and assurance that his chances for acceptance
were high due to this prep course.
Education and extra-curricular activities overlapped as a positive impact on participants.
The extra-curricular experiences were enhancements that supplemented the standard classroom
curriculum and the needs of persons of color. In higher education, associations for minority
students played a significant role in expanding exposure and providing supportive resources to
aid ethnically diverse students in their career choice.
Extra-Curricular Activities and Persons of Color Associations
Seven of the 12 research participants benefitted from enrichment programs and support
from minority associations. Respondents stated the value of these experiences and how these
supportive resources moved them along the clinical career continuum. Morris talked about his
enrichment experience:
At the end of my 1st year of college, I was able to have a 5- or 6-week experience in rural
Michigan with a primary care doctor. And this was organized by the university. I didn’t
have to do my own reach out to this person.
These findings signify that Morris felt relieved that the college arranged for this opportunity.
This outcome implied that entity-supported programs could secure higher-quality experiences
that Morris and other participants could not organize independently. Findings demonstrate the
supportive resource advantages of programs beyond the typical classroom.
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Phyllis, an African American with 14.5 years of experience as a practicing pediatrician,
contributed to the study with the following comments:
I had the opportunity to do multiple summer programs at the University of California
Berkeley, doing different math and science courses. And we had a chance to take a field
trip to UCSF’s campus and go to the cadaver lab. And that was probably the summer,
between my ninth and 10th grade at that point. And I was just really fascinated like, wow,
this is so cool. I definitely want to make sure that this is what I’m going to do.
Phyllis felt inspired and motivated by her extra-curricular experience. Without this firsthand lab
work experience, Phyllis may not have been encouraged to pursue medicine. Natasha shared
opportunities explicitly designed for racially and ethnically diverse students to increase minority
representation in medicine:
So, when I was in high school, I took STEM courses at UC Berkeley, where they had a
minority interested in science education summer and year-long programs. There was the
Imani Clinic, which was a student-run clinic, and the Minority Medical Education
Program.
Additionally, Natasha, Vicki, and Theresa mentioned minority-focused extra-curricular programs
sponsored by universities and private programs that were beneficial in reinforcing STEM
curricula and encouraging clinical medicine opportunities. Participation in programs designed for
persons of color included access to material meant to help students overcome the barriers of
ethnic underrepresentation and career opportunity exposure. Study participants felt the
information and tools met their needs as racially and ethnically diverse individuals pursuing a
medical career.
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In addition to academic benefits, Lola stated the added benefit of financial resource
guidance that these organizations offered:
Absolutely those types of groups [people of color associations] help me access funding
like scholarships for college tuition. Some programs in med school allowed access to
scholarships for global health and things like that to address health disparities. Accessing
those resources was crucial for me to grow.
The accessibility of financial support helped Lola undertake expenses associated with her
medical education and training. This finding indicated that Lola found relief in people of color-
oriented organizations’ resources. This experience supports the notion that organizations
designed to address the needs that disproportionately affect minoritized students help remove
obstacles that can delay advancement in their career journey.
Organizational resources such as university-sponsored programs and community courses
developed for individuals of color were valuable supportive resources for study participants.
These opportunities provided essential training needed for career preparation. Additionally,
mentorship is another category identified as a supportive resource. Respondents shared that
having a mentor is another factor that motivates career choice.
Mentorship
In the challenges and barriers section, the lack of a mentor led to uncertainty, confusion,
and sometimes a different career direction. According to six out of the 12 participants, having a
mentor provides the guidance and support necessary to continue the medical career path. Data
collected showed that mentorship came in various forms. Undergraduate and graduate advisors,
family friends, fellow students, and counselors were examples that emerged from the research.
Participants expressed that these relationships provided reliable consults, a person they could ask
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questions and share concerns, and someone who could help them navigate all the steps required
to become a doctor. Patty revealed her thoughts about mentorship and the advantage of having
representation that mirrored her gender and ethnicity:
I felt a little bit lost, but I had a very strong pre-med advisor. I worked in the lab of a
breast cancer surgeon who was also a family friend and a Black woman, the only Black
woman on the women’s faculty and surgery. And so, I was really blessed with good
mentoring in the process.
A mentorship relationship that reflected ethnicity and gender gave Patty confidence and
assurance, knowing she had a place in medicine. The mentorship was a strong motivator and
indicated that Patty felt empowered to have an example and a guide in the clinical space. The
mentorship, along with the representation, served as a model for Patty to emulate.
Morris offered that his undergraduate counselors were always available for questions or
problem-solving if an issue arose. He stated that these relationships helped personalize his career
course and provided advice that helped him evolve professionally. Morris felt encouraged to rely
on his mentors for assistance in his career pursuit of practicing medicine. Marie also shared that
mentorship was instrumental in helping her address challenges during residency. Having a
mentor in place provided a safety net for Marie and a guide to help her effectively address
problems that could have derailed her progress.
According to Theresa, having a formal mentorship program is optional. She described an
occurrence that demonstrated an organic approach to mentorship,
A couple of upper-classmen women would come and drag the freshman out. They were
pre-med. They would come around and say, “Do you have the study test, the old test that
you need to study for this exam?” And we go, “No.” So, having that kind of support was
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amazing, and that’s not a coordinated program. That’s just, you know, people looking out
for people.
The connection of experienced students provided a boost to Theresa. These encounters made her
feel like she had a reliable and caring support system. Knowing a group of individuals was
looking out for her academic well-being made her feel included and guaranteed she would not
fall through the cracks.
The level of comfort Lola experienced with her various mentors gave her security and
increased confidence in her ability to succeed. In addition, knowledgeable and engaged
professionals committed to her success were invaluable to Lola. These mentoring relationships
indicate that Lola was more likely to complete the necessary steps to progress along the clinical
medicine continuum.
Mentorship helped participants effectively navigate steps that led to a career in medicine.
Beyond one on one or small group mentoring, participants shared that the broader community
played a role in their career decision-making. Support from extended family or friends is an
additional resource for persons of color.
Community
The community was another supportive resource described by participants. A community
is a body of individuals with shared interests and characteristics living in a specific area
(Merriam-Webster, n.d.-a). For example, six out of 12 participants cited community resources:
friend groups, neighborhood, and religious organizations influenced their career choices.
Specifically, 50% percent of participants shared that peer support within their immediate
communities influenced their career journey.
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Greg described how his best friend stepped in to give him supportive resources that were
pivotal in navigating his career path:
The help of my best friend a genius, still best friends to this day. He helped me. He
tutored me through the difficult classes in college, helped me with my med school
application and interviews, drove me to some of the interviews, and really encouraged
me. If I didn’t have that, I wouldn’t be able to be sitting in front of you right now and
having an impact on the community.
Greg’s experience receiving tutoring from his friend indicated that a community could provide
adequate support critical to an individual’s success. This personal touch impacted Greg and was
one of the main factors that helped to achieve his career goal. The implication of personal
friendships that align with an individual’s goals is a powerful motivator.
A spiritual connection was a different kind of resource Marie relied on. Her religious
community offered emotional support:
I would have to say honestly, when I really think about it is just my faith and belief in
God. So, when I was really not feeling my best, I always would go home and go to
church, and there was just that community there to support me.
Marie’s reliance on her faith and spiritual community allowed her to regroup when feeling
vulnerable. In addition, the ability to have a safe environment to feel supported and upheld when
needed implies that emotional well-being is a factor in staying the course while pursuing a
medical career.
Attendance to an HBCU and/or Historically Black Medical School (HBMS) are
institutional communities cited in the research data as supportive resource systems. The data
showed that five out of the 12 research participants chose to complete their undergraduate and
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graduate medical school studies at these universities. Results from the study showed that all five
out of the 12 physicians who attended historically Black institutions found the experience to be
highly supportive, encouraging, and a great resource that aided their success. Phyllis described in
detail why these universities and medical schools are a tremendous resource for individuals of
color:
So, applying to medical school was a straightforward process. Xavier University, at that
time, really had the reputation of being the number one place to go if you were Black and
trying to get into medical school. They basically had a machine where they put you on
this trajectory and this path like, ‘These are the steps you do; these are the lines that you
follow.’ And I was guided, like, 100%. So, I was never on my own. I never had to try to
figure it out. I knew exactly what I was supposed to be doing, and all of my classmates
and friends were pre-med majors as well. So, we were all doing the same thing. The thing
that was just also unique about being at Meharry, and I’ve heard this from colleagues
who graduated from Howard or from Morehouse, is that we were all in it together. We’re
not there competing against each other. We’re all there trying to achieve the same goal at
the end of the day and rooting for each other and trying to support each other. There was
no, ‘Well, I have this information to study for this test, and I’m not going to share it with
my classmates, or I have this resource, and I’m not going to share it.’ There was none of
that at all. And the same with our teachers. Our professors were rooting for us.
Her fellow study participants who attended historically Black universities share Phyllis’s
account. These findings suggest that Phyllis and others felt the primary agenda for these
institutions was for all students to achieve their goal of becoming doctors. The administration,
faculty, deans, and fellow students worked in concert to minimize roadblocks in preparing future
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doctors of color with confidence. These research results suggest that attending an HBCU and
HBMS increases students of color’s ability to successfully achieve their goal of becoming
physicians by removing challenges and barriers associated with stereotype threat.
Findings showed several supportive resources participants used to help with their career
journey. The interviews shared examples of parents, STEM education, mentorship, extra-
curricular and persons of color-specific programs, and community. These factors demonstrated
how each category’s influence aided physicians to persist in becoming a doctor. Supportive
resources include influential factors that serve as career indicators for persons of color. These
influences were among many predictors of career advancement that inspired and motivated
participants’ desire to enter medicine.
Influences and Career Indicators
Another theme that impacted career decision-making is influences and career indicators.
Research participants cited many factors that inspired and motivated their desire to enter
medicine. The findings showed that a strong interest in science and math, ethnic representation,
and a willingness to help others indicated career achievement. However, all participants
mentioned parents and family as the leading influencer and career indicators.
Parents as Role Models and Cultural Influencers
Interview outcomes showed that parents and family members were participants’ most
effective encouragers and supporters. Of all those interviewed, 100% stated that their parents
positively influenced their journey. The data showed that parental and family support is an
essential career indicator for individuals of color hopefuls going into medicine.
The findings revealed that 50% of the research participants are first or second-generation
immigrants. The parents’ cultural mindset persuaded their children towards science careers.
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Those that identified as first or second-generation immigrants stated that their parents’
expectations began as small children, which set the course for their pursuit of medicine. Todd
shared his experience:
I had the whole immigrant mentality. When you’re raised by immigrants who come to
America, like they want better for you, and they know they come from places that don’t
afford you the kind of opportunities that America does. I was raised in a household where
there was no other option other than going to college. And even after going to college,
you had your next plans, like, “What are you doing after college? Are you going to go to
law school? Are you going to medical school? Are you going to go to nurse’s school, are
you going to become a doctor, engineer, a lawyer?” That was the mindset from the
moment you’re born.
Natasha added comments about her parents:
As I mentioned, I’m a first-generation Nigerian American, and really in our culture, you
have five professions that you can pursue. So, I didn’t really have a lot of choices. But it
was very clear. He [father] said, “My sons are going to be engineers, and my daughters
are going to be physicians.” And that’s exactly what happened. Both of my brothers are
software engineers, and my sister she’s finishing her residency in psychiatry. So, again,
very, very formative sort of upbringing.
This immigrant parental influence indicates when young children have expectations, there is a
higher chance of achieving professional goals.
My research study discovered that 40% of participants’ parents or close family members
were in healthcare either as nurses or physicians or were college-educated and employed in other
professional industries. Greg shared his parents’ influence:
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[Greg said jokingly] Almost all Filipinos are nurses, right? Medicine in our culture
played the part in my journey because it was familiar to me. It was my parents’ career.
They’ve had a 43- and 44-year journey, each of them as nurses, and they just retired.
This outcome implied a high likelihood that children of those in the medical profession or other
professional careers would follow. These pre-established beliefs assured participants they would
achieve their goals based on their parents’ role modeling, direction, and encouragement. In
addition to parental and family significant influence, respondents were motivated by their
scientific interest to choose a physician career.
Strong Interest in STEM
Another influencer and career indicator are a profound interest in STEM. This category
appeared in five out of the 12 participant interviews. Lola stated, “I was kind of naturally
interested in science.” Natasha also shared this enthusiasm for STEM, “I really enjoyed math and
science. Both of my parents were very supportive of that interest.” Marie commented, “I was
really good at math. Math was my favorite subject. So, when I arrived in college, I actually
thought about changing from medicine to actuary science.” Todd added, “I happen to decide to
become a doctor in college because I was really good at the health sciences. I enjoyed them. And
I think that’s how I got into medicine.” Effortless understanding of the sciences served as a
foundation for 40% of participants. Findings revealed that high interest in STEM catalyzes
learning more about the subject, ultimately influencing future career decisions.
Representation is essential to persons of color, especially in STEM-related fields. Though
the desire and aptitude for science were present for participants, more is needed to nudge persons
of color toward deciding on a medical career. A depiction of individuals that resemble your
identity attracts racially and ethnically diverse individuals to move toward clinical medicine.
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Ethnic Representation
Fifty percent of participants mentioned that ethnic representation was an influencer and
career indicator. Racially and ethnically diverse physician representatives prompted interviewees
to realize clinical medicine was a path they wanted to pursue. Greg shared, “There was one
Filipino doctor, but he was like Filipino Chinese, and my family said, ‘If you apply yourself, you
can be like him.’” Greg’s family used the Filipino Chinese physician as an example to show
Greg there is some representation and an opportunity to achieve in the same way he did. This
model indicated that Greg was encouraged that his goal of becoming a doctor was possible
despite his ethnicity. Natasha shared a similar experience:
I also had access to people who looked like me in medicine, so I could see myself as a
physician. So, those were the foundational, I think, experiences that sort of led me to
think about a career in medicine in healthcare.
Like Greg and Natasha, Vicki had a related experience where she encountered an African
American physician. She discussed how this exposure sealed her career decision:
Chicago Area Health Careers Program brought in the sort of exposure to various
underrepresented minority physicians and pharmacists and nurses, and all sorts of health
careers to expose us to those particular career paths. I remember vividly, like, wow, this
is how I’m going to be able to get into medical school and be a doctor. Like it was very
clear, and I think that was the turning point for everything.
Racial and ethnic representations created valuable insight for these participants. The images of
seeing someone who looked like them enabled them to envision their potential in the field. In
addition, findings implied that an example of practicing healthcare providers fueled study
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participants’ desire to enter the field of medicine. Results also revealed that the desire to help
others was another career decision motivator.
Desire to Help Others
Ten out of 12 (83%) of participants stated that a “desire to help others,” the second-
highest career indicator documented in the study, influenced them to become physicians. In
addition, the following sentiments from the research showed that the importance and strength of
their desire to help others was a critical influencing factor that drove their career decision.
Greg, Vicki, and Marie all confirmed their desire to support people. Greg offered, “I felt
like my own mission and purpose in life is to help people, and this [being a doctor] is a most
profound, direct way. I can do that.” Vicki added, “just overall wanting to help people. I knew in
a very early stage that there was a pathway for me.” Marie shared, “I really wanted to help
people, and so, I began to think about some of the career choices that I could have. And then I
made the choice.” Feedback from these participants inferred that a medical career aligned with
their early desire to make a difference in people’s lives. These findings suggest that Greg, Vicki,
Marie, and the additional seven participants feel accomplished doing something selfless and life-
changing—a goal bigger than themselves induced pride and satisfaction.
Some desires were specific to their racial and ethnic community. Research findings
showed that three out of 12 participants wanted to help individuals of color in marginalized
communities. Natasha explained her goal of becoming a physician:
My natural interest in wanting to take care of people, wanting to nurture people, and
wanting to be a leader is what you can do [as a doctor] to continue to pursue a passion
that you have and be of value and service to your community. And we are a very, very
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community-oriented culture in that it’s not really about the individual; it’s about everyone
around you have what they need.
Natasha’s emphasis on community indicated her commitment to those necessary to her.
Natasha’s need to care for others and be in a position of authority implied that choosing a
medical career would fulfill that desire. Patty shared an account that served as the inspiration to
help the African American community,
The one that triggered my pursuit in OB-GYN is I remember I was at Grady Hospital,
which is a big county hospital in Atlanta, and talking to a patient. She looked at me, a
young African American woman, maybe in her late 30s, early 40s, I don’t recall. And she
said, “Well, I don’t know anyone over age 45 who still has their uterus.” I was like,
“What?” The patient continued, “Of course, they have a hysterectomy; everybody needs a
hysterectomy.” I was like, hell no, we’re not doing this. I am not going to let Black
women’s uteruses just be snatched out without giving them options, giving them choices,
giving them a possibility of other procedures. This is another level of sterilization and
eugenics. No, I’m done. I’m going to be an OB-GYN for sure.
This defining moment solidified Patty’s career choice and persuaded her to specialize in
women’s healthcare. This experience suggests that Patty’s desire to protect those in her
community convinced her that healthcare was the best way to advocate for and defend Black
women. The desire to help individuals, be a leader to influence change, and support those in the
community who are vulnerable served as influencers for career choice.
The study identified challenges, barriers, supportive resources, influences, and career
indicators aligned with RQ 1. Eighteen factors influencing persons of color who pursue medicine
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were shown through data collected from the 12 interviews. The following section is a review of
data aligned with RQ 2.
Research Question 2
Research Question 2 asked the following: How does the representation of ethnic
minorities in clinical medicine impact health disparity outcomes for minoritized patients? The
gathered data for RQ 2 addressed ethnic physician representation and the impact of health
disparity outcomes for minoritized patients. Participants shared experiences of patients of color
and how their care can be influenced with or without underrepresented physicians of color in the
healthcare setting. The themes of patient benefits and challenges that emerged in the data and
numerous associating categories are outlined in the next section.
Minoritized Patient Benefits and Challenges
The advantages of treating marginalized patients by physicians of color significantly
decrease health disparities (NCHS, 2022). Physician participants in this study shared their
experiences and accounts of several gains achieved by being cared for within a multi-racial
cultural environment. The categories identified from the data include trust, treatment adherence,
communication, race, cultural concordance, fear minimization, variation of care, negative
experiences, and discrimination and prejudice.
Trust and Treatment Adherence
Patient trust and treatment adherence are areas where ethnic representation is vital for
patients. Fifty percent of respondents stated that ‘trust’ was a vast area where the presence of
underrepresented minorities in medicine (URiM) dramatically increased patients’ trust in
medical providers. Conversely, the lack of trust within the healthcare environment can lead to
adverse health outcomes for patients of color. Findings exemplified that patients are more
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inclined to receive care and follow treatment guidelines from someone they trust. Stan stated, “I
think part of trust is being similar. We tend to be more trustful of people that are similar to us,
just our nature.” Stan and other study participants shared that it is a natural tendency for
individuals to gravitate to what is familiar. Patients are more comfortable when their identities
(race, ethnicity, culture, or language) are present in a clinical setting. Most participants disclosed
that a significant advantage to trust is that patients listen to them. Vicki shared,
Because of the trust based upon my race, ethnicity, culture, they automatically believe
that I get it. Because they trust that what I’m saying, I’m not going to harm them. I’m not
just throwing prescriptions because I don’t have time to think about them and who they
are.
Vicki’s comment indicated that her value to the clinical setting helps encourage patients to feel at
ease and that they matter. Vicki’s knowledge of this shows her sense of purpose and the
satisfaction she received from comforting her patients. Six participants declared that patient
outcomes are tied to trust. Phyllis commented,
You can be the best doctor in the world and give the best care, the best treatment and
plan, and all of that, but if the patient doesn’t trust you or they don’t trust your motives,
and they don’t follow through with those recommendations, then they’re not necessarily
going to have a good outcome.
Phyllis’s story described how trust is a pivotal factor that can lead to better results if trust is
lacking. Phyllis and others feel trust fosters patient treatment compliance, leading to improved
health outcomes. Treatment adherence is vital for the overall well-being of the patient. It
promotes a partnered approach between provider and patient where the patient assumes an active
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role in their care. Lola described an experience where her involvement turned the course for a
patient:
I actually was able to get her to be more agreeable and on board with the treatment plan.
It wasn’t necessarily that the treatment plan was different from what the other physician
had recommended. But just because I was able to build that relationship with this person,
I was able to actually administer the treatment plan, and the patient trusted me in that
process.
These findings indicate that URiM physicians are successful in achieving patient compliance.
Phyllis offered another sentiment about treatment adherence and the positive impact of the
relationship:
Giving people access to providers that they felt really cared about them and that they felt
had their best interest at heart, and that they felt would really listen to them and would be
able to relate to them, I think, would make a world of difference in the care that people
had for themselves, as well as being able to make realistic changes.
The data showed that trusting relationships are essential to cultivating treatment adherence.
Patients who feel honored and cared for during clinical interactions are willing to make changes.
For example, Phyllis stated, “They’ll [patient] outright say, ‘Okay, I didn’t want to do it before
because I didn’t trust that other doctor, but I trust you, and I trust what you’re saying, and I
appreciate you listening.’” Phyllis’s patient’s account implies that change is possible if trust is
established and the patient feels heard. These sentiments are echoed throughout the findings of
this research.
These patient stories imply that trust fostered through cultural, ethnic, and racial
alignment is tied to acceptance of treatment guidelines. Treatment acceptance prompts a
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behavior change in the patient where essential medical recommendations are adopted and
followed. Findings indicate that compliance can improve healthcare outcomes.
Another area that was mentioned is communication. Communication between physician
and patient is essential for developing these trusting relationships. Listening to patients and
respecting their voices contributes to treatment adherence and the minimization of chronic
conditions.
Communication
Communication was a factor that emerged from the findings indicating a positive impact
on patient outcomes. The data underscored that communication could address language
differences and other cultural nuances. Stan recalled comments from his patients and how the
lack of communication influenced their patient-care encounters. He shared, “They [Hispanic
patients] talk how their experience is much different by seeing a Hispanic doctor than a White
doctor, and they feel more heard and understood.” These experiences indicate that Stan’s patients
feel comfortable sharing their preference for seeing an ethnically aligned physician. This level of
comfort fosters the feeling of acceptance and consideration. Being aware of these patient
preferences compelled Stan to ensure he is available to support his Hispanic patients, giving
them agency to express themselves and the assurance of psychological safety:
Lola shared a profound revelation when speaking with African American female patients:
So, many times, because I have the understanding, I feel comfortable talking to patients
about, “No, the government is not trying to sterilize you by putting in an IUD. This is
actually how it works.” But I think that for some providers without that kind of empathy
and understanding, they might feel less comfortable having that conversation and might
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not take the conversation as far when they don’t have that shared understanding of those
experiences.
Lola’s remarks suggest that the unwillingness of African Americans to undergo treatment is
influenced by historically poor treatment in the healthcare system. Being harmed is realistic for
Black patients, and their hesitancy is legitimate. Lola felt that because of who she is and her
understanding of prior unethical treatment, she effectively communicated to her patients the
reassurance needed to help them understand that no harm would occur and that they were safe.
These findings also indicated that non-minority physicians might not have this level of
understanding and concern which could prevent care compliance. Communication also considers
whether the patient feels honored and respected. Patty offered her perspective:
Patients should never be unheard so that they end up passed out on the floor. Our first
priority has to be patient safety and being respectful, addressing implicit bias, and really
working to be actively anti-racist is part of addressing patient safety.
The example Patty shared suggests that the issues of implicit bias and disrespect contribute to
insensitivity in the healthcare setting. These issues could provoke incidences where patient safety
is a factor. Patty believes systemic factors can cause profound communication problems where
complications can arise if the patient’s voice is dismissed.
Communication with patients, like other areas mentioned within patient benefits,
contributes to the overall patient experience. Findings show that the unique qualities physicians
of color bring to patient interactions can impact patient health outcomes. Similar results are
evident in racial, ethnic, and concordant provider/patient relationships.
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Race, Ethnic, and Cultural Concordance
Another area that impacts patient health outcomes is race, ethnicity, and cultural
concordance. Ten out of the 12 (83%) of respondents discussed the benefit of race, ethnicity, and
concordant cultural relationships. An additional discovery within the concordance relationship is
aligned language. The racial, ethnic, and cultural components are prominent, which is the central
focal point of the study; however, the research revealed that non-English-speaking patients are
more at ease and forthcoming when they can communicate in their native language. Provider and
patient relationships reflect these identities in each other. Morris said, “I think having kind of
that bicultural, bilingual experience opens opportunities for me to work with either individual
people or to work with families. There’s a lot more respect for differences.” Morris’s account
inferred that his cultural and linguistic diversity are characteristics favorable in the clinical
workspace. This ability helps Morris and other participants to gain essential information to
provide adequate care. Findings indicate that cultural alignment ensures accurate patient
assessment and reduced misinterpretation. Physician participants shared that patients desired a
physician that looked like them. Patty cites data that supports concordance in high-risk situations
and the potential of adverse outcomes when concordance is absent:
When you have a patient who is listened to more by their doctor, and you have that
cultural concordance, babies in the NICU had a lower mortality rate. So, when you have a
patient who is being listened to when she’s having a particular complaint and not being
ignored, you can make diagnostic findings earlier.
These findings suggest that concordant patient and provider relationships can help support
improved patient outcomes. Patty’s awareness of the patient and willingness to listen are
indicators that her alignment empowered her to ensure a good patient outcome. The data
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reinforced the preference for concordant relationships from patients. Carol added her experience
to the discussion: “I do find that African Americans try to get me as their doctor more than any
other person. They tell me, you know, I want somebody who looks like me. And when they ask,
I never say no.” Findings indicated that the comfort level of concordant relationships allowed
participants to speak directly with their patients within the boundaries of their shared culture
without needing to address race or ethnicity. The receptivity fostered by the concordant
relationship helps to produce a successful experience where patients feel heard. These
relationships are also linked to the minimization of fear. Like the benefits of trust, reducing
anxiety helps in the clinical setting. It can ease the tension a patient may feel in an environment
that historically has not supported minority patients.
Fear is an emotion triggered when there is a belief that danger is imminent from a person
or situation perceived as a threat (Merriam-Webster, n.d.-b). Based on the narratives from
research participants, fear can occur in the clinical setting, especially among minority patients.
Fear can stifle and cause anxiety; however, patients can engage and be present during clinical
encounters by reducing fear. Natasha shared a poignant story about a patient and how her
existence made a difference in this medical visit:
I had a patient, African American male, who was in tears when I walked into the room.
He told me that he had been sitting in his car for 30 minutes debating whether or not he
was going to come into the hospital because he didn’t know whom he was going to see.
And when I walked into the room, I mean the tears, this man in his late 50s, just tears
coming down. He said, “I know you were going to take care of me, sis.” This patient has
really put everything; he has invested so much in this relationship that I’ve got to make
sure he’s okay.
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The level of responsibility Natasha felt during this patient encounter is notable. His trust in her
motivated and persuaded her to do everything for him. Their shared racial, ethnic, and cultural
connection dissolved his fear, and he felt relieved just seeing a Black physician. Findings showed
a variety of challenges, including chronic health conditions that confronted patients. These
challenges were more prevalent in the experiences of patients of color and can contribute to
inconsistent care.
Medical Care Variation and Negative Experiences
Medical care variation and negative experiences can adversely impact patient health
outcomes. Eight out of 12 (67%) of physicians interviewed identified care variations and
negative experiences as crucial patient challenge areas. These difficulties exasperate existing
chronic conditions and potentially widen health disparities among racially diverse patients.
Physicians can influence the type of care a patient may receive. Stan explained,
Well, I have many patients that only speak Spanish, so when they talk to me, they always
tell me how the translators don’t do a good job of translating things with their doctor.
Obviously, you wonder about all the things that get missed through translation. When
you hear those experiences, you wonder, just by the fact that I’m Hispanic, and I can
understand where the patient is coming from and how different their care is.
This data showed that Stan believed his patient’s care could be varied if absent. Stan felt
important information that is overlooked could impact the patient’s health outcome. This
variation in care implied that Stan felt the system was unreliable and that issues could arise
without his or another Hispanic physician’s oversight. Missed diagnoses, inappropriate tests, and
ineffective treatment plans are potential outcomes that can occur and cause inconsistent care
(Wiltshire et al., 2011). Natasha described a situation of mistaken judgment:
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So, what does the physician do? Order tons of tests because they can’t get a good history
or understand when someone says that they have arthritis, but Haitian seniors call it
something different; you could mistake that for various things. If you aren’t someone
who understands that culture or couldn’t reach out to colleagues, or wasn’t curious
enough to ask that patient ‘when you say that you’ve got that pain deep in the bone, what
does that mean for you? Help me understand that.’ If you do not have that, then you’re
going to end up exposing patients to harm.
Natasha indicated that being inquisitive and asking questions are only sometimes done by non-
physicians of color. She and others feel this problem can trigger multiple errors in diagnosis and
treatment.
The potential issues with care variation are problematic during a clinical interaction
where language or cultural cues are not aligned. Missed cues can foster distrust and health
consequences that result from inappropriate treatment. Undoubtedly these situations are negative
and unfortunate. Findings showed that patients of color experienced several negative encounters
in healthcare settings. Some respondents for the study shared their own negative personal
healthcare encounters. For example, Lola described how she was diagnosed with non-pulmonary
tuberculosis (TB) as a young child. Since her mother was an immigrant and international travel is
a risk factor for TB transmission, the clinical staff assumed that Lola contracted the disease from
someone in her Filipino community. Lola recalled her mother’s reaction: “And I think, for my
mom, that made her feel as if she was dirty and didn’t belong.” Lola’s medical encounter implied
that immigrants and their country of origin are inferior. These assumptions rooted in implicit bias
affected Lola’s mother and made her feel shame. During her reflection as an adult, Lola could
discern the hypocrisy since neither Lola nor her mother did any recent international travel during
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that time. As a practicing physician, the research indicated that this negative experience
increased Lola’s empathy, connection, and understanding when working with immigrant patients
or other marginalized groups. This encounter suggests Lola feels compelled to provide
compassionate care to those minimized and discounted. However, these negative experiences can
be emotionally taxing, leaving the patients feeling like they do not matter because of their
differences.
Discrimination and Prejudice
Another challenge to patient-care outcomes is discrimination and prejudice. Twenty-five
percent of study members cited discrimination and bias in the medical setting as challenging for
patients of color seeking treatment and care. Morris shared his personal story of his mother’s
experience:
My mother came to this country not speaking English, and as a young child, seeing her
having those moments of struggling with people who are not very kind. I think that leaves
an impression on someone. When someone is having a hard time expressing themselves
in English, your brain just kind of thinks that maybe this person is not very smart.
Like Lola’s story, Morris’ mother’s treatment made him uncomfortable and embarrassed.
However, as a physician, this data implies Morris also feels compassion and is aware of the
judgment among non-minoritized providers. Making prejudicial judgments based on identity
cues is something that Carol has seen during her time as a care provider. She surmised,
You can be diverse and not sympathetic or empathetic to other groups. There is a lot of
racism in the medical system, and we, as doctors, must stop. I don’t want to say judging,
but we tend to put people into little boxes when we see them. You walk into a room, and
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you see a Black person, and you look at the chart, and you start making judgments
already.
Here, Carol described racism that exists among ethnic groups as well. Though most
discrimination toward persons of color is from White individuals, findings showed that is not
always true. Anyone can hold bias; therefore, judging is prevalent, but Carol believes physicians
must make the change so judgment will not interfere with care.
Prejudicial thinking has caused harm emotionally and physically. For example, Black
women are seen as “tough” and “unable to feel pain” in the birthing process; therefore, are
ignored if they protest or ask for relief. Patty said, “When you ignore those voices, that has real
medical consequences.” Patty’s comment is another example of the historic medical
mistreatment of African Americans based on fallacies from prejudicial non-scientific evidence.
As a Black female physician, Patty feels obligated to counter this misinformation by promoting
improved patient listening and honoring their wishes.
Similarly, Todd’s interview outlined his leader’s derogatory behavior toward patients. He
described his experience:
I’ll never forget one of my chief residents, this Italian American guy, the way he would
talk about a former patient and would treat her, at times, made me uncomfortable. It
bordered on the line of being racist or kind of off-putting. But he was also my chief, so I
never challenged or questioned him.
Based on Todd’s comments, those in positions of power can discriminate and perpetuate
prejudicial attitudes and conclusions. These observations suggest that though Todd felt uneased
by the egregious behavior, he did not feel authorized to speak out because of the power dynamic.
This discriminatory behavior indicates a hostile environment where Todd may be less inclined to
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confront authority; instead, he might direct his attention to ensuring his clinical encounters are
thoughtful, positive, compassionate, and supportive. The advantages of treating marginalized
patients by physicians of color significantly decrease health disparities (Walker et al., 2012).
Patient benefits and challenges experienced in the clinical setting are prevalent due to the
underrepresentation of racially and ethnically diverse physicians. Findings indicate that the
benefits of trust, treatment adherence, provider and patient racial concordance, and
communication make a difference to marginalized patients. These factors provide safety,
increased treatment compliance, comfort, respect, and improved health outcomes. However,
challenges of medical care variation, negative experiences, discrimination, and prejudice can
adversely impact patients’ well-being allowing health disparities to persist in these vulnerable
communities.
Summary
Challenges and barriers, supportive resources, influences, career indicators, and
minoritized patient benefits and challenges were the main themes that emerged from my study.
Research participants provided rich data for each theme and supporting categories that addressed
each RQ. In the following chapter, I will discuss how these findings tell us about the factors that
influence individuals of color to choose a career in clinical medicine, the impact of
representation in addressing minoritized patient health outcomes, and career indicators for
persons of color who successfully achieve becoming a physician. Finally, the chapter concludes
by providing recommendations to improve representation.

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Chapter Five: Recommendations
This study aimed to identify career indicators influencing the decision-making and
achievement of persons of color to become physicians and how their representation can impact
health disparities among minoritized groups. Discovering career pursuit indicators for people of
color can help inform strategies and approaches to increase racial and ethnic-diverse
representation in clinical medicine. The external and internal motivators for why minorities
pursue medicine, the indicators for successful career attainment, and their commitment to closing
the health disparity gap within minority groups are analyzed. The study applied the conceptual
framework of Bronfenbrenner’s (1979) ecological systems and the motivational framework of
Bandura’s (1997, 2001) self-efficacy theory. Bronfenbrenner’s (1979) four ecological settings,
microsystem, mesosystem, exosystem, and macrosystem, exist external to the individual and are
used as critical lenses to examine their influence on the participants’ career journey. Bandura
(1997, 2001) defined self-efficacy as a person’s belief in their skills to control their behavior and
external events to achieve a goal. This applied lens analyzes individuals’ self-judgments about
their abilities to perform successfully or not and the reciprocal influence of self-regulated
behavior needed for goal achievement.
Two RQs guided this study:
1. What factors influence minorities to choose a career in clinical medicine?
2. How does the representation of ethnic minorities in clinical medicine impact health
outcomes for minoritized patients?
Qualitative semi-structured interviews of 12 ethnically diverse active physicians were
conducted to collect and analyze data that addressed the RQs. Findings from the study were
documented in the previous chapter. This chapter discusses these findings, how the results align
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with the published literature, and the conceptual and motivational frameworks. Next, the
limitation and delimitations will be outlined, followed by proposed recommendations for
practice. Finally, the chapter will finish with suggestions for future research and study
conclusions.
Discussion of Findings
The findings of my study aligned with the prior reviewed literature and conceptual
framework of Bronfenbrenner’s (1979) ecological systems and the motivational framework of
Bandura’s (1997, 2001) self-efficacy theory. Bronfenbrenner’s ecology of human development
theory investigates how the external environment impacts individual development. Settings
represent how these exterior spaces are connected to the person. The individual, which includes
sex, age, health, and socioeconomic status, is the center of the surrounding settings. Beyond the
individual, we move externally into the four settings of the ecological framework. The
microsystem setting is closest to the individual and focuses on family, school, peers, church, and
neighborhood. The following setting is the mesosystem which bridges the microsystem and
exosystem. The exosystem includes an extension of family members, friends, and school,
expanding the individual’s connection to societal services, legal, social welfare, and mass media.
The macrosystem is the most outer external setting, which includes cultural attitudes and
ideology (Bronfenbrenner, 1979). Per Bandura (1997, 2001) self-efficacious beliefs are
fundamental to self-regulated motivation in determining whether one’s behavior will support or
obstruct goal attainment. The main themes from the study findings include challenges and
barriers, supportive resources, influences, career indicators, minoritized patient benefits, and
challenges. Literature-reviewed studies were linked to the theme findings, and the theoretical and
motivational frameworks identified the internal and external factors that influence ethnic
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minority clinical career decision-making and the impact of underrepresentation on healthcare for
underserved minority patients.
Research Question 1 explored challenges and barriers, supportive resources, influence,
and career indicators. The ecological systems associated with these themes are the microsystem
and mesosystem, the two closest settings connected to the individual in the ecological conceptual
framework. These themes are directly related to the individual and have the most significant
impact on their development. When analyzing categories that emerged within the themes,
overlapping areas, literature alignment with previous studies, and discrepancies were discovered.
Within supportive resources, influence, and career indicators, three categories spanned
these themes: parents and family, extra-curricular activities, and HBCU and HBMS attendance.
Parents and family fall within Bronfenbrenner’s (1979) microsystem setting, the nearest layer to
the individual. Participants expressed the importance of these close connections and the positive
impact that parents and family had on their career journey. These findings were noted in the
outcomes of my research study; however, the literature review highlighted the effect on
individuals when parents and family support are absent. Freeman et al.’s (2016) research study
showed minority students cited that a lack of personal and family support contributed to
diminished interest in medicine. Compared to the literature, my analysis showed evidence that
when the elements of supportive parents and family are present, it is implied that the lack of
interest in a medical career can be reduced.
Extra-curricular activities and HBCU and HBMS attendance extend to the mesosystem
setting. The mesosystem setting is the area between the microsystem and exosystem,
representing the interaction between the inner layer of the individual’s influence and the next
step beyond the nucleus of family, neighborhood, peers, and school. Findings showed that
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additional STEM programs beyond the classroom were factors in gaining knowledge and
competence that led to successful preparation for further advancement in the medical field. In the
previously conducted literature review, extra-curricular activities and HBCU and HBMS were
not documented. This could be because the literature focused on the barriers and challenges of
considering medicine instead of factors that can offset deterrents. However, the literature
reviewed revealed a connection between successful STEM experience, academic self-efficacy,
and mentorship. The literature showed that mentors encouraged self-efficacious behavior, which
resulted in improved academic success and elevated STEM achievement (Holloway-Friesen,
2021; Wood et al., 2015; Yelorda et al., 2021). My research implies that these supportive
resources and career choice influencers favorably affect an individual’s career path within
clinical medicine.
STEM education is nested in the microsystem and mesosystem settings. Additionally,
STEM education was a category that appeared in all the themes, such as challenges and barriers,
supportive resources, influences, and career indicators. My study showed that the lack of STEM
in K–12 was confused with course requirements that triggered delays in preparation for the rigors
of the undergraduate STEM curriculum. Primary education rests within the microsystem, the
nearest setting to the individual with the most significant impact. This finding implies that early
education could substantially affect persons of color pursuing a medical career. The literature
review supported this finding and indicated that the lack of STEM education during early
academic years was a challenge for minority students that impacted academic preparedness and
caused eligibility barriers for STEM-related careers (Griffin et al., 2017; MacPhee et al., 2013).
Conversely, upon examining exposure to K–12 STEM education, the evidence showed a positive
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outcome. Again, part of the microsystem, STEM as a supportive resource became a favorable
influence and career indicator for becoming a physician.
Challenges, barriers, and supportive resources shared the common factors of mentorship
and ethnic representation. Like STEM education, lacking either of these factors can create
disadvantages, and having these same factors can produce advantages for emerging physicians of
color. Mentorship and ethnic representation can live in multiple ecological settings:
microsystem, mesosystem, and exosystem. The proximity of the environment setting to the
person determines the level of adverse or positive impact on individual development. In the
microsystem, close friends, school, or family that are mentors or persons of color representatives
in medicine significantly impact the individual reaching their goal. Mentors and ethnic
representatives in higher education and residency that reside in the mesosystem and exosystem
have a lesser effect on the individual’s development.
Challenges of not being mentored and lack of ethnic role models emerged in the research
findings and literature review as a source of problems in becoming a doctor (AAMC, 2019;
Freeman et al., 2016). On the other hand, these same factors can bolster physician hopefuls if
present in the lives of persons of color. The positive impact of formal and informal mentorship
ranked high in the study findings. In the literature, mentoring showed increased academic self-
efficacy for graduate students of color (Holloway-Friesen, 2021). In addition, study participants
who saw representation as a child with a racially concordant doctor, exposure to physicians
during an extra-curricular activity, or in their graduate program benefited from seeing what is
possible.
The inference is that these areas contribute to career influences for future clinical
medicine practitioners. The literature review did not include representation in the context of a
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career choice influencer. Like extra-curricular activities and HBCU and HBMS attendance, the
literature focused on the barriers, challenges, and reasons for needed representation as opposed
to factors that counter physician career pursuits. One of the dominant categories of challenges
and barriers was discrimination. The forms of discrimination mentioned were implicit bias,
microaggressions, and prejudicial thinking based on stereotypes. This category overlapped with
RQ 2 as it pertained to variation of care and negative encounters for patients of color.
Participants shared that microaggressions, implicit bias, and prejudice were most evident in the
mesosystem, exosystem, and macrosystem settings. Environments that displayed this behavior
towards persons of color were predominately White higher academic institutions and the clinical
workspace. Within the microsystem, participants noted that microaggressions and prejudice were
also apparent in primary education. Discrimination and all its forms were documented
significantly in the reviewed literature. Discrimination and prejudice were cited as environmental
and social determinants that exclude equitable education, employment, housing, and access to
care for persons of color, which significantly impact their ability to choose a medical career
(Brondolo et al., 2011; Horowitz et al., 2019; Lucey & Saguil, 2020; Paradies et al., 2015).
Self-efficacy was referred to by five out of the 12 participants within challenges and
barriers and influences, and career indicators. This motivational framework by Bandura (1997,
2001) solely focused on the individual’s belief in their skills to achieve a goal. This framework
identifies various components that can impact an individual’s self-efficacy. Performance
experience, vicarious experience, social persuasion, imaginal experience, and physical and
emotional stress can influence an individual’s behavior. Within challenges and barriers, data,
self-doubt, and low perception created mental obstacles tied to physical and emotional stress that
could affect motivation in pursuing a medical career. The literature reviewed aligns with this
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finding stating that individuals of color with low self-efficacy perceive barriers are too hard to
overcome in becoming a doctor and lose interest (Pajares, 1996, 2002; Yelorda et al., 2021).
High self-efficacy was significant in the research data for influences and career indicators. The
confidence instilled by parents, mentors, same-gender education, and cultural identity emerged in
the findings. Similarly, we found in the reviewed literature that high self-efficacy influenced by
vicarious and imaginal experiences through relationships with mentors was significant. The
literature also noted that high self-efficacy was a deterrent to negative experiences resulting from
racism and prejudice (Byars-Winston et al., 2010; MacPhee et al., 2013).
Research Question 2 studied the experiences of minority patients and how their care can
be influenced with or without physicians of color in the healthcare setting. The macrosystem
lens, the outermost setting of the conceptual framework, was applied to examine the influences
of social norms, culture, national institutions, and systems. In the clinical physician-patient
relationship context, the healthcare system is within the macrosystem setting. Systems like
healthcare aligned in the macrosystem have widespread impact and influence on the individual
and the larger community. The theme of minoritized patient benefits and patient challenges
emerged from the findings. Categories documented as benefits for patients were trust, treatment
adherence, communication, minimization of fear, and racial, ethnic, and cultural concordance.
The patient challenges included a variation of care, negative experiences, and discrimination and
prejudice.
Findings showed that the benefit of ethnically aligned physician representation
corresponded with data cited in the literature review. Previous studies showed provider-patient
race, cultural, gender, and linguistic concordance improved trust, treatment adherence, and
communication, which are linked to decreased mortality in critical care settings and overall
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better health outcomes (Alsan et al., 2019; Schoenthaler et al., 2014; Traylor et al., 2010). My
study supported the reviewed literature, with participants sharing how patients preferred racial,
cultural, and linguistic concordance and how these encounters influenced increased treatment
compliance and trust.
The research findings and literature review recorded discrimination and prejudice within
the patient challenges. These areas of variation of care and negative experience are outcomes due
to discrimination and perceived prejudicial attitudes. Literature review showed that persons of
color experience extended wait times before being seen, prior experiences of inferior healthcare
led to mistrust and poor communication increased fear and sadness (Bazargan et al., 2022;
Cuevas et al., 2016; Griffith et al., 2021). Within the context of discrimination in healthcare,
African Americans have a unique experience due to historical atrocities. The study outcomes and
the literature review aligned with the historical aspects of discriminatory treatment toward
African American patients. The Tuskegee Syphilis experiment and experiments conducted by
Dr. Marion Sims were noted in the literature as two historical events where experimental tests
and procedures were done at the expense and peril of African American men and women (CDC,
2021c; Jacobs et al., 2006; Wailoo, 2018). Twenty-five percent of study participants provided
examples of historical fallacies and atrocities about African American patients.
The findings address the problem of practice by providing evidence that the
underrepresentation of ethnic minorities is an issue and that increasing representation can impact
the health outcomes of minoritized patients. My research reveals how increasing the pipeline
with committed, diverse persons of color can improve the health outcomes of marginalized
patients. Health disparities are linked to lack of access, mistrust, cultural and linguistic barriers,
poor communication, and discrimination. My study showed that racial, ethnic, and diverse
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physicians have the understanding needed for positive provider-patient concordant experiences
that improve treatment adherence, communication, and trust. The findings also provide evidence
that these external factors within Bronfenbrenner’s (1979) ecological settings of the
microsystem, mesosystem, and exosystem and Bandura’s (1997, 2001) self-efficacy framework
indicate a strong influence on the individual’s capacity for success. These factors of supportive
resources, influencers, career indicators like parents and family, ethnic representation in the
medical field, community resources, mentorship, extra-curricular activities, persons of color
organizations, and STEM education can improve the likelihood that persons of color will choose
a medical career. In addition, findings revealed that individuals’ internal self-efficacious drivers
of a strong interest in the sciences and the desire to help others showed a greater probability of
becoming a physician despite the challenges of discrimination, prejudice, lack of STEM
education, lack of mentorship, lack of ethnic representation, and lack of finances.
After reviewing, comparing, and contrasting the research findings and previous literature,
the data analysis indicates straightforward influencers and career indicators for physicians of
color who pursue clinical medicine. Despite the challenges and barriers, these themes and areas
demonstrated a pathway for success if these elements were present. The research and literature
also confirm that addressing underrepresentation can significantly benefit patients of color by
reducing health disparities and improving care outcomes.
Recommendations for Practice
This section recommends increasing persons of color in clinical medicine to help
minimize health disparities and improve care outcomes among marginalized minority groups.
Study findings support the recommendations to increase ethnically diverse physician
representation and its impact on positive patient outcomes. The three practice recommendations
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proposed are organizational in scope and are targeted at large healthcare systems that employ
active physicians and contain residency programs for physicians in training. Implementation of
these recommendations will require stakeholders from various internal and external sectors.
These stakeholders include leadership from human resources, physician medical groups,
residency programs, HBMS, community colleges, and high schools.
The Kotter (1996) eight-step change model will be used to implement all the practice
recommendations. Developed by John Kotter in 1996 as part of his work Leading Change, this
model is a comprehensive approach that considers essential areas of organizational change.
Figure 3 illustrates each component of Kotter’s eight-step change model.

Figure 3
Kotter’s Eight-Step Change Model

Note. Illustration of Kotter’s eight-step model. Adapted from Leading Change by J. P. Kotter,
1996. Harvard Business Press. Copyright 1996 by John P. Kotter.
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Recommendation 1: Recruit Medical Students of Color From Historically Black Medical
Schools and International Medical Schools in our Residency Programs
In my study, six out of 12 interview participants went to HBMSs or medical schools
outside of the United States in a country with significant individuals of color populations. The
representation of faculty, chairs, and Black medical students in HBMS is more effective than in
any other medical school institution nationally (Parsons et al., 2022). International medical
students represent many ethnicities and cultures and are considered well-suited to address and
support the needs of the growing immigrant population (Pierre et al., 2017). These educational
institutions and health organizations are part of Bronfenbrenner’s (1979) macrosystem which
focuses on the broader external influences of the individual. Recruitment strategies that match
healthcare institutions’ residency programs with a predominant study body of ethnically diverse
medical students strengthen the individual’s ability to enter the field and, over time, increase
representation.
Recommendation 2: Mentorship Programs in Undergraduate and Graduate Medical
Education
Six out of 12 interviewees declared that mentorship was essential in undergraduate,
graduate, and entering clinical practice. These mentor relationships supported the application
process, test taking, choosing a specialty focus, and psychological safety in settings where people
of color were significantly underrepresented. A study of over 300 Hispanic graduate students
disclosed that mentoring was essential to positive self-efficacy. Like African American students,
having community and relationships with mentoring faculty showed an increase in academic
self-efficacy (Holloway-Friesen, 2021). Mentors of color in positions of authority, faculty, and
senior leadership are essential to help up-and-coming physicians of color enter the workforce
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pipeline successfully and continue to grow in their careers (Titanji & Swartz, 2021). Mentorship
is part of Bronfenbrenner’s (1979) mesosystem setting, bringing together influencers that help
motivate and guide medical students and active physicians through obtaining and maintaining a
medical career. We also see mentorship through the lens of Bandura’s (1997, 2001) motivational
self-efficacy framework to foster improved academic outcomes. Organizations establishing
mentor programs for undergraduate, graduate, residents, and practicing physicians of color is an
investment that will help curb dissatisfaction, and isolation, secure retention, and improve
representation (Pacheco et al., 2022).
Recommendation 3: Pipeline Programs for Middle and High School Students of Color
Seven out of 12 interview participants stated that involvement in extra-curricular health
profession programs which target middle and high school students of color influenced their
career decision and helped to prepare them for undergraduate pre-medical studies. Healthcare
pipeline programs for the youth of color empower their career choices to pursue medicine and
cultivate a diverse physician workforce (Danner et al., 2017). Successful pipeline programs for
youth include the individual’s attitudes, values, and perceptions of their ability to achieve a
medical career (Holden et al., 2014). The individual and microsystem settings in
Bronfenbrenner’s (1979) ecological theory are integral in early intervention pipeline programs.
Bandura’s (1997) self-efficacy theory is also a component of a young person’s attitude and belief
in themselves to succeed.
The Kirkpatrick four-level evaluative tool will be used to measure the effectiveness of
each practice recommendation (Kirkpatrick & Kirkpatrick, 2016). It is essential to incorporate an
evaluation with any intervention program to identify areas of improvement, assess if a
meaningful change occurred, and demonstrate the program’s value to organizational
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stakeholders. The first level in the evaluation tool is ‘reaction.’ This level determines if the
participants found the practice recommendation satisfactory and relevant to their education,
training, and work. The second level is ‘learning,’ which focuses on improved knowledge and
skills based on the information participants learned from the training. Level 3 is behavior. This
level refers to the transference of knowledge that creates a behavior change. Finally, the fourth
level covers ‘results,’ desired outcomes that occurred based on the program. Using the
Kirkpatrick framework to evaluate these efforts will produce invaluable feedback to see if the
vision or objectives are met. For example, if recruiting efforts fall short of reaching a 25%
increased racial and ethnic minority physician representation within 3 years, reviewing the vision
or goal to determine how best to adjust the outreach plan is possible by looking at feedback. As
an accountability mechanism, it allows stakeholder groups to ask questions about results for
those responsible for goal outcomes to see how best to address the gap and use the results to
inform an effective solution. This evaluative tool works well because it captures the critical
elements within each Kotter’s change model step. Figure 4 shows each component of the
Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2016).

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Figure 4
Kirkpatrick Evaluation Framework

Note. Adapted from Kirkpatrick’s Four Levels of Training Evaluation by J. D. Kirkpatrick & W.
K. Kirkpatrick, 2016. ATD Press. Copyright 2016 by James D. Kirkpatrick and Wendy Kayser
Kirkpatrick.

Though the Kirkpatrick model is used for training programs, the principles can be applied
to the practice recommendations for future change. An example of Level 4 outcomes is applied
to the resident recruitment program as an example. See Table 2, which illustrates the outcome,
metric, and method.

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Table 2
Kirkpatrick Level 4 Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External outcomes
Establish contractual
relationships with two or
more historically HBMS.
Two or more HBMS agree to
partner with recruitment
efforts.
Healthcare organizations and
HBMS partners meet for
monthly strategy meetings
about outreach and
placement of medical
students of color.
The number of HBMS junior
and senior medical school
students participating in
residency planning events.
Physician director and
residency physician leaders
join HBMS medical school
leadership for a joint
presentation to medical
students.
Collaborate with a national
non-profit partner
committed to physician
diversity to host a
healthcare career summit
for youth in elementary
school through college.
Host one summit annually
with a national non-profit
committed to increasing
physician diversity in
healthcare.
Healthcare organization
departments and non-profit
national group plan,
organize, and host a
summit.
Internal outcomes
Healthcare organization
stakeholders’ endorsement
Stakeholders: Board of
directors, executive
physician leadership, staff
physicians, and patient
members
Approve budget for incentive
packages and fee waiver.
Provide organization support
assessment.
Increase satisfaction among
minority and non-minority
physician stakeholders.
The number of physician
resident faculty and
minority physicians
involved in the recruitment
initiative
HR data of the total number
of senior, associate, and
participant physicians that
practice within the
organization. From the total
number of physicians,
determine the percentage
that participated in the
recruitment initiative
Waive application fee for
minority resident applicants
to increase recruitment of
residents of color by 25%.
The number of applications
received by individuals of
color applicants with fee
waiver compared to the
Data review of applications
received before and after
fee waiver
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Outcome Metrics Methods
number of applications
received by individuals of
color applicants before fee
waiver
For in-demand specialties,
monetary incentive
packages are offered upon
completion of residency for
minority doctors to stay
with the medical group.
The number of specialty
groups with high patient
demand, high physician
turnover, and external
referrals for patients that
need sub-specialty access
Review all medical centers’
statistics for each data
point.
The number of minority
residents that plan to
practice within one of the
desired specialty groups
Identify which specialties are
the priority from the data
review.

Limitations and Delimitations
The limitation of my study that is beyond my control is interview availability. Physicians
are very busy and prefer time with family or friends when not in the clinic. Many responses to
the interview invitation will be favorable, but the actual scheduling will be difficult. Though an
interview may get scheduled, there is a high risk of postponement or cancellation without
rescheduling. Another limitation is the responses from some of the participants. The questions
may not apply to a particular group’s experience or do not have the same meaning. For example,
someone from a specific Asian group (Chinese, East Indian) may not view underrepresentation
as an issue because they have high representation in clinical medicine.
The delimitation of the study is that my original focus was the underrepresentation of African
American men in healthcare. I chose to broaden the study to include other ethnic minorities. This
choice to increase the scope of participants can have a delimiting impact on participant
availability. With a larger group, the chances of securing interviews are more significant, but
111

schedules will still be a factor. Despite impacted schedules, I am better positioned to obtain 12–
20 physicians with an expanded group.
Recommendations for Future Research
For future research, I recommend studying the challenges, influences, and career
indicators for ethnic minority physicians who were generationally born, raised, and nurtured in
the United States. Specifically, those that descended from African enslaved people and
Indigenous American people. Fifty percent (six out of 12) of my participants were first or
second-generation immigrants. The mindset and values their parents instilled impacted their
ability to overcome challenges and barriers to success. One participant noted that the treatment
and messages African Americans receive in the United States from birth indicate they have a
prescribed role that does not include professional science careers. This observation supports the
idea that Blacks and Indigenous Americans who are native to the United States have a different
experience due to the legacy of enslavement, genocide, Jim Crow, the criminal justice system,
and ongoing racial, systemic, and institutional racism.
African American and Indigenous American physicians are the second-lowest
represented ethnic groups in healthcare (AAMC, 2019). For those physicians that did achieve
their goal, it would benefit the research to find their influences, indicators, and gaps so that
intervention and work can be done to increase their representation. In addition, diverse cultural
experiences unique to this country are essential in healthcare to help further minimize the gap in
health disparities.
Conclusion
The study intended to provide research that illustrates the need for a racial and ethnic-
diverse physician workforce. Additionally, to supply supporting evidence of how diverse
112

representation can improve health outcomes by decreasing disparities within minoritized groups.
Finally, identify extrinsic and intrinsic career pursuit indicators for people of color that can help
inform how to support the growth of racial and ethnic-diverse representation in clinical medicine.
Health disparities are a chronic public health issue in our healthcare systems (NCHS,
2022). Evidence from the literature review indicated that racial, ethnic, and lingual concordant
relationships were essential to address poor health outcomes (NCHS, 2022; Schoenthaler et al.,
2014). My study showed that these relationships improve the health of patients of color. In
addition, findings showed that concordant relationships tackle issues associated with poor health
outcomes, such as mistrust, fear, and poor communication, by fostering treatment adherence,
safety, and trust.
Lack of access to quality care is problematic for persons of color. By 2034, the United
States will have an estimated shortage of between 17,800 and 48,000 physicians, and the
projected population in 2060 will be 32% non-White racial and ethnic minorities. Physicians
from marginalized and underrepresented communities are more likely than White physicians to
practice in underserved areas with a high minority population (Colby & Ortman, 2015; Peabody
et al., 2018). Evidence from my study showed that eight out of 12 physicians practice in primary
care. Primary care includes adult and family medicine, obstetrics and gynecology, and pediatrics.
These areas of medicine are the frontline specialties that practice preventive care and are the first
entry point for patients of color.
Health disparities and inequities, access to care for vulnerable groups, and population
considerations that impact public health provide the evidence that supports the need for
physicians, specifically racially and ethnically diverse physician providers. The supportive
resources, influences, and career indicators that emerged from my study provided insight into
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increasing representation. These findings provide evidence to inform pathways to encourage an
increase in underrepresented groups to successfully pursue medicine and improve the health of
those most in need.

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References
Adair, J. K. (2015). The impact of discrimination on the early schooling experiences of children
from immigrant families. Migration Policy Institute.
Adler, G., Glymour, M. M., & Fielding, J. (2016). M. M., & Fielding, J. (2016). Addressing
social determinants of health and health inequalities. Journal of the American Medical
Association, 316(16), 1641–1642. https://doi.org/10.1001/jama.2016.14058
Alcendor, D. J. (2020). Racial disparities-associated COVID-19 mortality among minority
populations in the US. Journal of Clinical Medicine, 9(8), 1–17.
https://doi.org/10.3390/jcm9082442
Alsan, M., Garrick, O., & Graziani, G. (2019). Does diversity matter for health? Experimental
evidence from Oakland. The American Economic Review, 109(12), 4071–4111.
https://doi.org/10.1257/aer.20181446
American Psychological Association. (2020). Publication manual of the American Psychological
Association (7th ed.). https://doi.org/10.1037/0000165-000
Association of American Medical Colleges. (2019). Diversity in medicine: Facts and figures
2019. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-
figures-2019
Association of American Medical Colleges. (2020). Diversity and inclusion: Underrepresented
in medicine definition. https://www.aamc.org/what-we-do/equity-diversity-
inclusion/underrepresented-in-medicine
Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of
Psychology, 52(1), 1–26. https://doi.org/10.1146/annurev.psych.52.1.1
115

Bazargan, C., Cobb, S., & Assari, S. (2021). Discrimination and medical mistrust in a racially
and ethnically diverse sample of California adults. Annals of Family Medicine, 19(1), 4–
15. https://doi.org/10.1370/afm.2632
Bazargan, C., Cobb, S., Assari, S., & Bazargan-Hejazi, S. (2022). Preparedness for Serious
Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health
Communication. The American Journal of Hospice & Palliative Care, 39(4), 461–471.
https://doi.org/10.1177/10499091211036885
Bohrnstedt, G., Kitmitto, S., Ogut, B., Sherman, D., & Chan, D. (2015). School composition and
the Black-White achievement gap (NCES 2015-018). National Center for Education
Statistics.
Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kash, B. A., Schulze, A., &
Helduser, J. W. (2015). Rural Healthy People 2020: New decade, same challenges. The
Journal of Rural Health, 31(3), 326–333. https://doi.org/10.1111/jrh.12116
Boserup, B., McKenney, M., & Elkbuli, A. (2020). Disproportionate impact of COVID-19
pandemic on racial and ethnic minorities. The American Surgeon, 86(12), 1615–1622.
https://doi.org/10.1177/0003134820973356
Boslaugh, S. (2010). Secondary data source. In N. J. Salkind (Ed.), Encyclopedia of research
design (pp. 2–3). SAGE Publications, Inc., https://doi.org/10.4135/9781412961288.n406
Bowser, B. P. (2017). Racism: Origin and theory. Journal of Black Studies, 48(6), 572–590.
https://doi.org/10.1177/0021934717702135
Brondolo, E., ver Halen, N. B., Libby, D., & Pencille, M. (2011). Racism as a psychosocial
stressor. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science: Biology,
psychology, and health (pp. 167–184). Springer Publishing Company.
116

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design. Harvard University Press.
Burkholder, G. J., Cox, K. A., Crawford, L. M., & Hitchcock, J. H. (Eds.). (2019). Research
design and methods: An applied guide for the scholar-practitioner. Sage Publications.
Byars-Winston, A., Estrada, Y., Howard, C., Davis, D., & Zalapa, J. (2010). Influence of social
cognitive and ethnic variables on academic goals of underrepresented students in science
and engineering: A multiple-groups analysis. Journal of Counseling Psychology, 57(2),
205–218. https://doi.org/10.1037/a0018608
Canning, E. A., Muenks, K., Green, D. J., & Murphy, M. C. (2019). STEM faculty who believe
ability is fixed have larger racial achievement gaps and inspire less student motivation in
their classes. Science Advances, 5(2). https://doi.org/10.1126/sciadv.aau4734
Centers for Disease Control and Prevention. (2017). Vital signs: Racial disparities in age-
specific mortality among Blacks or African Americans — United States, 1999–2015.
https://www.cdc.gov/mmwr/volumes/66/wr/mm6617e1.htm?s_cid=mm6617e1_w
Centers for Disease Control and Prevention. (2020). Adolescent and school health. Health
disparities. https://www.cdc.gov/healthyyouth/disparities/
Centers for Disease Control and Prevention. (2021a). Racism and health.
https://www.cdc.gov/healthequity/racism-disparities/index.html
Centers for Disease Control and Prevention. (2021b). Rural communities.
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/other-at-risk-
populations/rural-communities.html#print
Centers for Disease Control and Prevention. (2021c). The U.S. Public Health Service syphilis
study at Tuskegee. The Tuskegee Timeline. https://www.cdc.gov/tuskegee/timeline.htm
117

Chin, M. J., Quinn, D. M., Dhaliwal, T. K., & Lovison, V. S. (2020). Bias in the air: A
nationwide exploration of teachers’ implicit racial attitudes, aggregate bias, and student
outcomes. Educational Researcher, 49(8), 566–578.
https://doi.org/10.3102/0013189X20937240
Chu, W., Wang, N., Choi, Y. S., & Roby, D. H. (2021). The effect of patient-centered
communication and racial concordant care on care satisfaction among U.S. immigrants.
Medical Care Research and Review: MCRR, 78(4), 404–412.
https://doi.org/10.1177/1077558719890988
Claeys, A., Berdai-Chaouni, S., Tricas-Sauras, S., & De Donder, L. (2021). Culturally sensitive
care: Definitions, perceptions, and practices of health care professionals. Journal of
Transcultural Nursing, 32(5), 484–492. https://doi.org/10.1177/1043659620970625
Clark-Hitt, R., Malat, J., Burgess, D., & Friedemann-Sanchez, G. (2010). Doctors’ and Nurses’
Explanations for Racial Disparities in Medical Treatment. Journal of Health Care for the
Poor and Underserved, 21(1), 386–400. https://doi.org/10.1353/hpu.0.0275
Clayborne, E. P., Martin, D. R., Goett, R. R., Chandrasekaran, E. B., & McGreevy, J. (2021).
Diversity pipelines: The rationale to recruit and support minority physicians. Journal of
the American College of Emergency Physicians Open, 2(1), Article e12343.
https://doi.org/10.1002/emp2.12343
Cohen, R. A., Cha, A. E., Martinez, M. E., & Terlizzi, E. P. (2020). Health insurance coverage:
Early release of estimates from the National Health Interview Survey, 2019. National
Center for Health Statistics. https://www.cdc.gov/nchs/nhis/healthinsurancecoverage.htm
Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S.
population: 2014 to 2060 (Current Population Reports, P25-1143). U.S. Census Bureau.
118

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed
methods approach. Sage publications.
Cuevas, A., & O’Brien, K. (2019). Racial centrality may be linked to mistrust in healthcare
institutions for African Americans. Journal of Health Psychology, 24(14), 2022–2030.
https://doi.org/10.1177/1359105317715092
Cuevas, A. G., O’Brien, K., & Saha, S. (2016). African American experiences in healthcare: “I
always feel like I’m getting skipped over.” Health Psychology, 35(9), 987–995.
https://doi.org/10.1037/hea0000368
Cunningham, T. J., Croft, J. B., Liu, Y., Lu, H., Eke, P. I., & Giles, W. H. (2017). Vital signs.
Racial disparities in age-specific mortality among Blacks or African Americans —
United States, 1999–2015. MMWR. Morbidity and Mortality Weekly Report, 66(17),
444–456. https://doi.org/10.15585/mmwr.mm6617e1
Dall, T., Reynolds, R., Chakrabarti, R., Jones, K., & Iacobucci, W. (2020). The complexities of
physician supply and demand: Projections from 2018 to 2033. Association of American
Medical Colleges. https://www.aamc.org/data-reports/workforce/data/complexities-
physician-supply-and-demand-projections-2018-2033
Dall, T., Reynolds, R., Chakrabarti, R., Jones, K., & Iacobucci, W. (2021). The complexities of
physician supply and demand: Projections from 2019 to 2034. Association of American
Medical Colleges. https://www.aamc.org/data-reports/workforce/data/complexities-
physician-supply-and-demand-projections-2019-2034
Danner, O. K., Lokko, C., Mobley, F., Dansby, M., Maze, M., Bradley, B., Williams, E.,
Matthews, L. R., Harrington, E., Mack, L., Clark, C., Wilson, K., Beech, D., Heron, S., &
Childs, E. (2017). Hospital-based, multidisciplinary, youth mentoring and medical
119

exposure program positively influences and reinforces health care career choice: “The
Reach One Each One Program early experience.” American Journal of Surgery, 213(4),
611–616. https://doi.org/10.1016/j.amjsurg.2016.12.002
Davis, G., & Allison, R. (2013). White coats, Black specialists? Racial divides in the medical
profession. Sociological Spectrum, 33(6), 510–533.
https://doi.org/10.1080/02732173.2013.836143
Davis, J., Penha, J., Mbowe, O., & Taira, D. A. (2017). Prevalence of single and multiple leading
causes of death by race/ethnicity among US adults aged 60 to 79 years. Preventing
Chronic Disease, 14, Article 160241. https://doi.org/10.5888/pcd14.160241
de Brey, C., Musu, L., McFarland, J., Wilkinson-Flicker, S., Diliberti, M., Zhang, A.,
Branstetter, C., & Wang, X. (2019). Status and Trends in the Education of Racial and
Ethnic Groups 2018. NCES 2019-038. National Center for Education Statistics. U.S.
Department of Education., https://nces.ed.gov/pubsearch/
Douthit, K., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to
health care access in the rural USA. Public Health, 129(6), 611–620.
https://doi.org/10.1016/j.puhe.2015.04.001
Dweck, C. S. (2008). Mindset: The new psychology of success. Random House Digital, Inc.
Elliot, A. J., Dweck, C. S., & Yeager, D. S. (2017). Handbook of competence and motivation:
theory and application (2nd ed.). The Guilford Press.
Fabes, R. A., Quick, M., Catherine, E., & Musgrave, A. (2021). Exclusionary discipline in U.S.
public schools: A comparative examination of use in Pre-Kindergarten and K–12 grades.
Educational Studies, ahead-of-print(ahead-of-print), 1–18.
https://doi.org/10.1080/03055698.2021.1941782
120

Freeman, B. K., Landry, A., Trevino, R., Grande, D., & Shea, J. A. (2016). Understanding the
leaky pipeline: Perceived barriers to pursuing a career in medicine or dentistry among
underrepresented-in-medicine undergraduate students. Academic Medicine, 91(7), 987–
993. https://doi.org/10.1097/ACM.0000000000001020
Frenkiewich, J., & Onosko, J. J. (2020). Public schools at-risk. Examining a century of U.S.
media coverage of “unsatisfactory student performance” and the rise of school
privatization. Democracy & Education, 28(2).
Funk, C., & Parker, K. (2018). Women and men in STEM often at odds over workplace equity.
Pew Research Center.
Greenaway, C., Hargreaves, S., Barkati, S., Coyle, C. M., Gobbi, F., Veizis, A., & Douglas, P.
(2020). COVID-19: Exposing and addressing health disparities among ethnic minorities
and migrants. Journal of Travel Medicine, 27(7), Article taaa113. Advance online
publication. https://doi.org/10.1093/jtm/taaa113
Griffin, C. B., Cooper, S. M., Metzger, I. W., Golden, A. R., & White, C. N. (. (2017). School
racial climate and the academic achievement of African American high school students:
The mediating role of school engagement: School racial climate and academic
achievement. Psychology in the Schools, 54(7), 673–688.
https://doi.org/10.1002/pits.22026
Griffith, B., Bergner, E. M., Fair, A. S., & Wilkins, C. H. (2021). Using mistrust, distrust, and
low trust precisely in medical care and medical research advances health equity.
American Journal of Preventive Medicine, 60(3), 442–445.
https://doi.org/10.1016/j.amepre.2020.08.019
121

Hall, G. L., & Heath, M. (2020). Poor medication adherence in African Americans is a matter of
trust. Journal of Racial and Ethnic Health Disparities, 8(4), 927–942.
https://doi.org/10.1007/s40615-020-00850-3
Harrell, C. J. P., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green,
S. (2011). Multiple pathways linking racism to health outcomes. Du Bois Review, 8(1),
143–157. https://doi.org/10.1017/S1742058X11000178
Henke, R. M., Lopez-Gonzales, L., Wang, D., Goetzel, R. Z., Montes, M., Winick, K., &
Crighton, K. A. (2015). Racial and ethnic disparities in health among employees at large
firms. Journal of Occupational and Environmental Medicine, 57(6), 627–634.
https://doi.org/10.1097/JOM.0000000000000460
Hinga, B. (2021). Paradigms of inquiry [Recorded lecture]. USC Rossier School of Education.
https://2sc.rossieronline.usc.edu/ap/courses
Holden, L., Rumala, B., Carson, P., & Siegel, E. (2014). Promoting careers in health care for
urban youth: What students, parents and educators can teach us. Information Services &
Use, 34(3-4), 355–366. https://doi.org/10.3233/ISU-140761
Holloway-Friesen, H. (2021). The role of mentoring on Hispanic graduate students’ sense of
belonging and academic self-efficacy. Journal of Hispanic Higher Education, 20(1), 46–
58. https://doi.org/10.1177/1538192718823716
Honey, M., & Kanter, D. E. (2013). Introduction. In M. Honey (Ed.) Design, make, play:
Growing the next generation of science innovators (pp. 19–24). Routledge.
https://doi.org/10.4324/9780203108352-5
122

Hooper, M. W., Napoles, A. M., & Perez-Stable, E. J. (2020). COVID-19 and racial/ethnic
disparities. Journal of the American Medical Association, 323(24), 2466–2467.
https://doi.org/10.1001/jama.2020.8598
Horowitz, J. M., Brown, A., & Cox, K. (2019). Race in America 2019. Pew Research Center.
Jacobs, E. A., Rolle, I., Ferrans, C. E., Whitaker, E. E., & Warnecke, R. B. (2006).
Understanding African Americans’ views of the trustworthiness of physicians. Journal of
General Internal Medicine: JGIM, 21(6), 642–647. https://doi.org/10.1111/j.1525-
1497.2006.00485.x
Jetty, A., Hyppolite, J., Eden, A. R., Taylor, M. K., & Jabbarpour, Y. (2022). Underrepresented
minority family physicians more likely to care for vulnerable populations. Journal of the
American Board of Family Medicine, 35(2), 223–224.
https://doi.org/10.3122/jabfm.2022.02.210280
Jordan, P. (2019). Attendance playbook: Smart solutions for reducing chronic absenteeism.
FutureEd: https://www.future-ed.org/wp-content/uploads/2019/07/Attendance-
Playbook.pdf.
Khan, S. Q., de Gonzalez, A. B., Best, A. F., Chen, Y., Haozous, E. A., Rodriquez, E. J.,
Spillane, S., Thomas, D. A., Withrow, D., Freedman, N. D., & Shiels, M. S. (2018).
Infant and youth mortality trends by race/ethnicity and cause of death in the United
States. JAMA Pediatrics, 172(12), Article e183317.
https://doi.org/10.1001/jamapediatrics.2018.3317
Kim, E. J., Marrast, L., & Conigliaro, J. (2020). COVID-19: Magnifying the effect of health
disparities. Journal of General Internal Medicine, 35(8), 2441–2442.
https://doi.org/10.1007/s11606-020-05881-4
123

Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick’s four levels of training Evaluation.
ATD Press.
Kotter, J. P. (1996). Leading change. Harvard Business Press.
Laurencin, C. T., & Murray, M. (2017). An American crisis: The lack of Black men in medicine.
Journal of Racial and Ethnic Health Disparities, 4(3), 317–321.
https://doi.org/10.1007/s40615-017-0380-y
Lucey, C. R., & Saguil, A. (2020). The consequences of structural racism on MCAT scores and
medical school admissions: The past is prologue. Academic Medicine, 95(3), 351–356.
https://doi.org/10.1097/ACM.0000000000002939
Lyon, A. (2017, October 10). Epistemology, Ontology, and Axiology in Research [Video].
YouTube. https://www.youtube.com/watch?v=AhdZOsBps5o
MacPhee, D., Farro, S., & Canetto, S. S. (2013). Academic self-efficacy and performance of
underrepresented STEM majors: Gender, ethnic, and social class patterns. Analyses of
Social Issues and Public Policy (ASAP), 13(1), 347–369.
https://doi.org/10.1111/asap.12033
Marjoua, Y., & Bozic, K. J. (2012). Brief history of quality movement in US healthcare. Current
Reviews in Musculoskeletal Medicine, 5(4), 265–273. https://doi.org/10.1007/s12178-
012-9137-8
Marrast, L. M., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority
physicians’ role in the care of underserved patients: Diversifying the physician workforce
may be key in addressing health disparities. JAMA Internal Medicine, 174(2), 289–291.
https://doi.org/10.1001/jamainternmed.2013.12756
124

Martin, S. A., Harris, K., & Jack, B. W. (2015). The health of young African American men.
Journal of the American Medical Association, 313(14), 1415–1416.
https://doi.org/10.1001/jama.2015.2258
Maxwell, J. A. (2013). Qualitative research design: An interactive approach. Sage publications.
McBride Murry, V., Berkel, C., Gaylord-Harden, N. K., Copeland-Linder, N., & Nation, M.
(2011). Neighborhood poverty and adolescent development. Journal of Research on
Adolescence, 21(1), 114–128. https://doi.org/10.1111/j.1532-7795.2010.00718.x
Medical University of the Americas. (2021). What is a medical resident?
https://www.mua.edu/resources/blog/what-is-a-medical-resident-and-how-long-is-the-
residency
Merriam, S. B., & Tisdell, E. J. (2015). Qualitative research: A guide to design and
implementation (4th ed.). Jossey-Bass.
Merriam-Webster. (n.d.-a). Community. In Merriam-Webster.com dictionary. Retrieved March
21, 2023, from https://www.merriam-webster.com/dictionary/community
Merriam-Webster. (n.d.-b). Fear. In Merriam-Webster.com dictionary. Retrieved March 22,
2023, from https://www.merriam-webster.com/dictionary/fear
Merriam-Webster. (n.d.-c). Person of color. In Merriam-Webster.com dictionary. Retrieved April
18, 2023, from https://www.merriam-webster.com/dictionary/person
Merriam-Webster. (n.d.-d). Resource. In Merriam-Webster.com dictionary. Retrieved March 21,
2023, from https://www.merriam-webster.com/dictionary/resource
Milliones, J. (1980). Construction of a Black consciousness measure: Psychotherapeutic
implications. Psychotherapy, 17(2), 175–182. https://doi.org/10.1037/h0085908
125

Mireles-Rios, R., Rios, V. M., & Reyes, A. (2020). Pushed out for missing school: The role of
social disparities and school truancy in dropping out. Education Sciences, 10(4), 108–.
https://doi.org/10.3390/educsci10040108
Moreau, A., Carol, L., Dedianne, M. C., Dupraz, C., Perdrix, C., Lainé, X., & Souweine, G.
(2012). What perceptions do patients have of decision making (DM)? Toward an
integrative patient-centered care model. A qualitative study using focus-group interviews.
Patient Education and Counseling, 87(2), 206–211.
https://doi.org/10.1016/j.pec.2011.08.010
Morgan, K. P. (2018). Describing the emperor’s new clothes: Three myths of educational (in-)
equity. In A. Diller, B, Houston, K. P. Morgan, & M. Ayim (Eds.), The gender question
in education (pp. 105–122). Routledge. https://doi.org/10.4324/9780429496530-11
Naidoo, K., Yuhaniak, H., & Abel, Y. (2020). An ecological systems approach to exploring
facilitators and barriers to success for minority students enrolled in a Doctor of Physical
Therapy program. Health Profession Education, 6(3), 394–405.
https://doi.org/10.1016/j.hpe.2020.06.001
Nation, M., Christens, B. D., Bess, K. D., Shinn, M., Perkins, D. D., & Speer, P. W. (2020).
Addressing the problems of urban education: An ecological systems perspective. Journal
of Urban Affairs, 42(5), 715–730. https://doi.org/10.1080/07352166.2019.1705847
National Center for Health Statistics. (2022). Healthy People 2020 final review.
https://doi.org/10.15620/cdc:111173.
National Prevention Council. (2011). National prevention strategy. US Department of Health
and Human Services, Office of the Surgeon General.
http://www.healthcare.gov/center/councils/nphpphc
126

Nazione, S., Perrault, E. K., & Keating, D. M. (2019). Finding common ground: Can provider-
patient race concordance and self-disclosure bolster patient trust, perceptions, and
intentions? Journal of Racial and Ethnic Health Disparities, 6(5), 962–972.
https://doi.org/10.1007/s40615-019-00597-6
Okech, A. P., & Harrington, R. (2002). The relationships among Black consciousness, self-
esteem, and academic self-efficacy in African American men. The Journal of Psychology,
136(2), 214–224. https://doi.org/10.1080/00223980209604151
Pacheco, N., Trinh, N. H., Jahan, A., Mensah, M., Felix, G., Clark, F., Strong, S., & Hairston, D.
(2022). Dismantling structural racism in psychiatric residency training: Nurturing a new
generation of Black, Indigenous, and People of Color (BIPOC) psychiatrists. Academic
Psychiatry, 46(5), 657–662. https://doi.org/10.1007/s40596-022-01678-1
Pajares, F. (1996). Self-efficacy beliefs in academic settings. Review of Educational Research,
66(4), 543–578. https://doi.org/10.3102/00346543066004543
Pajares, F. (2002). Gender and perceived self-efficacy in self-regulated learning. Theory Into
Practice, 41(2), 116–125. https://doi.org/10.1207/s15430421tip4102_8
Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., &
Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-
analysis. PLoS One, 10(9), Article e0138511.
https://doi.org/10.1371/journal.pone.0138511
Parsons, M., Caldwell, M., Alvarez, A., Davenport, D., Gallegos, M., Landry, A., Gottlieb, M.,
& Natesan, S. (2022). Physician pipeline and pathway programs: An evidence-based
guide to best practices for diversity, equity, and inclusion from the Council of Residency
127

Directors in Emergency Medicine. The Western Journal of Emergency Medicine, 23(4),
514–524. https://doi.org/10.5811/westjem.2022.2.54875
Patton, M. Q. (2002). Qualitative research and evaluation methods. Sage.
Peabody, E., Eden, A. R., Douglas, M., & Phillips, R. L. (2018). Board certified family physician
workforce: Progress in racial and ethnic diversity. Journal of the American Board of
Family Medicine, 31(6), 842–843. https://doi.org/10.3122/jabfm.2018.06.180129
Pierre, J. M., Mahr, F., Carter, A., & Madaan, V. (2017). Underrepresented in medicine
recruitment: Rationale, challenges, and strategies for increasing diversity in psychiatry
residency programs. Academic Psychiatry, 41(2), 226–232.
https://doi.org/10.1007/s40596-016-0499-x
Quinn, D. M. (2017). Racial attitudes of pre-K–12 and postsecondary educators: Descriptive
evidence from nationally representative data. Educational Researcher, 46(7), 397–411.
https://doi.org/10.3102/0013189X17727270
Rao, V., & Flores, G. (2007). Why aren’t there more African-American physicians? A
qualitative study and exploratory inquiry of African-American students’ perspectives on
careers in medicine. Journal of the National Medical Association, 99(9), 986–993.
Reardon, S. F., Valentino, R. A., & Shores, K. A. (2012). Patterns of Literacy among U.S.
Students. The Future of Children, 22(2), 17–37. https://doi.org/10.1353/foc.2012.0015
Reid, K. W. (2013). Understanding the relationships among racial identity, self-efficacy,
institutional integration and academic achievement of Black males attending research
universities. The Journal of Negro Education, 82(1), 75–93.
https://doi.org/10.7709/jnegroeducation.82.1.0075
128

Robinson, S. B., & Leonard, K. F. (2019). Designing quality survey questions. Sage
Publications.
Roncoroni, J., Frank, M., Hudson, A., Whitaker, S., Edelman, A., Garcia, P., Leeper, E.,
Carrasco, V., Melendez, D., & Ratchford, J. (2021). Latinx Patients’ perceptions of
culturally sensitive health care and their association with patient satisfaction, patient-
provider communication, and therapeutic alliance. Journal of Racial and Ethnic Health
Disparities, 9(2), 620–629. https://doi.org/10.1007/s40615-021-00994-w
Rothman, S., Gunturu, S., & Korenis, P. (2020). The mental health impact of the COVID-19
epidemic on immigrants and racial and ethnic minorities. QJM: Monthly Journal of the
Association of Physicians, 113(11), 779–782. https://doi.org/10.1093/qjmed/hcaa203
Rumberger, R. W. (2020). The economics of high school dropouts. In S. Bradley & C. Green
(Eds.), The economics of education: A comprehensive overview (2nd ed., pp. 149–158).
Academic Press.
Salkind, N. J. (Ed.). (2010). Encyclopedia of research design. SAGE.
Saunders, M., Lewis, P., & Thornhill, A. (2007). Research methods for business students (4th
ed.). Pearson Education Limited.
Schoenthaler, A., Allegrante, J. P., Chaplin, W., & Ogedegbe, G. (2012). The effect of patient–
provider communication on medication adherence in hypertensive Black patients: Does
race concordance matter? Annals of Behavioral Medicine, 43(3), 372–382.
https://doi.org/10.1007/s12160-011-9342-5
Schoenthaler, A., Montague, E., Baier Manwell, L., Brown, R., Schwartz, M. D., & Linzer, M.
(2014). Patient-physician racial/ethnic concordance and blood pressure control: The role
129

of trust and medication adherence. Ethnicity & Health, 19(5), 565–578.
https://doi.org/10.1080/13557858.2013.857764
Schunk, D. H., & Mullen, C. A. (2012). Self-efficacy as an engaged learner. In S. L. Christenson,
A. L. Reschly, & C. Wylie (Eds.), Handbook of research on student engagement (pp.
219–235). Springer US. https://doi.org/10.1007/978-1-4614-2018-7_10
Shrider, E. A., Kollar, M., Chen, F., & Semega, J. (2021). Income and poverty in the United
States: 2020 (Current Population Reports). U.S. Census Bureau.
https://www.census.gov/library/publications/2021/demo/p60-273.html
Smedley, B. D., Butler, A. S., & Bristow, L. R. (Eds.). (2004). In the nation’s compelling
interest: Ensuring diversity in the health-care workforce. National Academies Press.
Smith, S. G., Nsiah-Kumi, P. A., Jones, P. R., & Pamies, R. J. (2009). Pipeline programs in the
health professions, part 1: Preserving diversity and reducing health disparities. Journal of
the National Medical Association, 101(9), 836–851. https://doi.org/10.1016/S0027-
9684(15)31030-0
Starck, J. G., Riddle, T., Sinclair, S., & Warikoo, N. (2020). Teachers are people too: Examining
the racial bias of teachers compared to other American adults. Educational Researcher,
49(4), 273–284. https://doi.org/10.3102/0013189X20912758
Sudol, N. T., Guaderrama, N. M., Honsberger, P., Weiss, J., Li, Q., & Whitcomb, E. L. (2021).
Prevalence and nature of sexist and racial/ethnic microaggressions against surgeons and
anesthesiologists. JAMA Surgery, 156(5), Article e210265.
https://doi.org/10.1001/jamasurg.2021.0265
130

Tai, D. B. G., Shah, A., Doubeni, C. A., Sia, I. G., & Wieland, M. L. (2021). The
disproportionate impact of COVID-19 on racial and ethnic minorities in the United
States. Clinical Infectious Diseases, 72(4), 703–706. https://doi.org/10.1093/cid/ciaa815
Tenenbaum, H. R., & Ruck, M. D. (2007). Are teachers’ expectations different for racial
minority than for European American students? A meta-analysis. Journal of Educational
Psychology, 99(2), 253–273. https://doi.org/10.1037/0022-0663.99.2.253
Titanji, B. K., & Swartz, T. H. (2021). A Diverse Physician-Scientist Pipeline to Fight Structural
Racism. Clinical Infectious Diseases, 73(1), 151–155.
https://doi.org/10.1093/cid/ciaa1387
Traylor, A. H., Schmittdiel, J. A., Uratsu, C. S., Mangione, C. M., & Subramanian, U. (2010).
Adherence to cardiovascular disease medications: Does patient-provider race/ethnicity
and language concordance matter? Journal of General Internal Medicine, 25(11), 1172–
1177. https://doi.org/10.1007/s11606-010-1424-8
Tucker, C. M., Arthur, T. M., Roncoroni, J., Wall, W., & Sanchez, J. (2015). Patient-centered
culturally sensitive health care. American Journal of Lifestyle Medicine, 9(1), 63–77.
https://doi.org/10.1177/1559827613498065
U.S. Census Bureau. (2021a). 2020 census illuminates racial and ethnic composition of the
country. https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-
measures-reveal-united-states-population-much-more-multiracial.html
U.S. Census Bureau. (2021b). Measuring racial and ethnic diversity for the 2020 census.
https://www.census.gov/newsroom/blogs/random-samplings/2021/08/measuring-racial-
ethnic-diversity-2020-census.html
131

U.S. Department of Health and Human Services. (2019). National healthcare quality and
disparities report, 2018. www.ahrq.gov/research/findings/nhqrdr/index.html
Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic turning points for the United
States: Population projections for 2020 to 2060. US Census Bureau.
Vogenberg, F. R. (2019). US healthcare trends and contradictions in 2019. American Health &
Drug Benefits, 12(1), 40–47.
Wailoo, K. (2018). Historical aspects of race and medicine: The case of J. Marion Sims. Journal
of the American Medical Association, 320(15), Article 1529–1530.
https://doi.org/10.1001/jama.2018.11944
Walker, K. O., Moreno, G., & Grumbach, K. (2012). The association among specialty, race,
ethnicity, and practice location among California physicians in diverse specialties.
Journal of the National Medical Association, 104(1-2), 46–52.
https://doi.org/10.1016/S0027-9684(15)30126-7
Wiltshire, J. C., Person, S. D., & Allison, J. (2011). Exploring differences in trust in doctors
among African American men and women. Journal of the National Medical Association,
103(9-10), 845–851. https://doi.org/10.1016/S0027-9684(15)30439-9
Wood, J. L., Newman, C. B., & Harris, F. (2015). Self-efficacy as a determinant of academic
integration: An examination of first-year Black males in the community college. The
Western Journal of Black Studies, 39(1), 3–17.
World Health Organization. (2018). Health inequities and their causes.
https://www.who.int/news-room/facts-in-pictures/detail/health-inequities-and-their-
causes
132

Xierali, I. M., & Nivet, M. A. (2018). The racial and ethnic composition and distribution of
primary care physicians. Journal of Health Care for the Poor and Underserved, 29(1),
556–570. https://doi.org/10.1353/hpu.2018.0036
Xu, K., Nosek, B., & Greenwald, A. (2014). Psychology data from the race implicit association
test on the project implicit demo website. Journal of Open Psychology Data, 2(1), Article
e3. https://doi.org/10.5334/jopd.ac
Yelorda, K., Bidwell, S., Fu, S., Miller, M. O., Merrell, S. B., Koshy, S., & Morris, A. M.
(2021). Self-efficacy toward a healthcare career among minority high school students in a
surgical pipeline program: A mixed methods study. Journal of Surgical Education, 78(6),
1896–1904. https://doi.org/10.1016/j.jsurg.2021.04.010

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Appendix A: Forms of Racism Regarding Racial and Ethnic Disparities
The following tables present the internal psychological representation and mediators of
physiological impact for each form of racism.

Table A1
Effects of Four Forms of Racism
Forms or
facets of
racism
Examples Internal psychological
representation
Mediators of
physiological impact
Structural Chronic poverty,
unemployment, and
failed infrastructure
in non-White
communities
Conditioned links between
dire context and race;
schema reflecting
racialized disparities
Reduced sense of well-
being; worry and
rumination; racist
schema
Cultural Individual and
institutional
devaluation and
misrepresentation of
non-Western and
non-White cultural
products and values
Schema and values
reflecting negative
evaluations of non-
White cultural products
and values
Reduced valuing of one’s
culture; alienation
from cultural roots;
negative affect
Institutional Actions of educational
and employment
institutions
discriminate against
African people.
Reactions to and episodic
memory of denied
access; negative sense
of self (individual and
collective) in schema
Appraisal and coping
processes; reduced
well-being, increased
worry; suppression and
unconscious reactions
Individual Discriminatory acts
against people of
color
Reactions to and episodic
memory of personal
insult or unfair
treatment
Appraisal and coping
processes; reduced
well-being, increased
worry; suppression and
unconscious reactions

Note. Adapted from “Multiple Pathways Linking Racism to Health Outcomes” by C. J. P.
Harrell, T. I. Burford, B. N. Cage, T. M. Nelson, S. Shearon, A. Thompson & S. Green, 2011.
Du Bois Review, 8(1), p. 151. (https://doi.org/10.1017/S1742058X11000178). Copyright 2011 by
W. E. B. Du Bois Institute for African and African American Research.
134

Tables A2 to A6 present the largest disparities by race/ethnicity.

Table A2
Largest Disparities for Blacks
Examples of measures with the largest disparities
New HIV cases per 100,000 population age 13 and over.
HIV infection deaths per 100,000 population.
Hospital admissions for asthma per 100,000 population, children ages 2-17.

Note. Adapted from National Healthcare Quality and Disparities Report by U.S. Department of
Health and Human Services, 2019. (www.ahrq.gov/research/findings/nhqrdr/index.html). In the
public domain.

135

Table A3
Largest Disparities for Latinos
Examples of measures with the largest disparities
New HIV cases per 100,000 population age 13 and over.
Home health patients who had influenza vaccination during flu season.
HIV infection deaths per 100,000 population.

Note. Adapted from National Healthcare Quality and Disparities Report by U.S. Department of
Health and Human Services, 2019. (www.ahrq.gov/research/findings/nhqrdr/index.html). In the
public domain.

Table A4
Largest Disparities for Asians
Examples of measures with the largest disparities
Adults with limited English proficiency and a usual source of care (USC) whose USC had
language assistance.
Adults who reported that home health providers always treated them with courtesy and respect
in the last 2 months of care.
Adults who reported that home health providers always treated them as gently as possible in
the last 2 months of care.

Note. Adapted from National Healthcare Quality and Disparities Report by U.S. Department of
Health and Human Services, 2019. (www.ahrq.gov/research/findings/nhqrdr/index.html). In the
public domain.

136

Table A5
Largest Disparities for American Indian and Alaska Natives (AI/Ans)
Examples of measures with the largest disparities
Hospital patients who received influenza vaccination.
Infant mortality per 1,000 live births, birth weight 2,500 grams or more.
New HIV cases per 100,000 population age 13 and over.

Note. Adapted from National Healthcare Quality and Disparities Report by U.S. Department of
Health and Human Services, 2019. (www.ahrq.gov/research/findings/nhqrdr/index.html). In the
public domain.

Table A6
Largest Disparities for Native Hawaiians and Pacific Islanders
Examples of measures with the largest disparities
Adults who received a blood pressure measurement in the last 2 years and can state whether
their blood pressure was normal or high.
Hospital patients who received influenza vaccination.
Adults who reported that home health providers always treated them with courtesy and respect
in the last 2 months of care.

Note. Adapted from National Healthcare Quality and Disparities Report by U.S. Department of
Health and Human Services, 2019. (www.ahrq.gov/research/findings/nhqrdr/index.html). In the
public domain.

137

Appendix B: Study Information Sheet
The purpose of the study information sheet is to provide the participant with an overview
that includes interview process, study focus, type of study and interview questions.
Introductory Remarks
Thank you again for agreeing to participate in the interview. I appreciate the time you
have set aside to answer my questions. The interview should take about an hour, and depending
on how you feel we have the flexibility to end early or go beyond the hour. I am solely operating
in the capacity of a 2nd-year doctoral student of USC’s Rossier School of Education within the
Organizational Change and Leadership program. In the event, that something changes you can
reach me through the following channels:
• School email: lweaverr@usc.edu
• Mobile: 444-444-4444
• IRB Approval Number: UP-22-00714
Study of Interest
My focus is to understand how the lack of physician racial and ethnic diversity leads to
health disparities among minoritized groups and how increasing racial and ethnic representation
is a viable approach to decrease health disparities.
Type of Study
This will be a qualitative research study using interviews and a literature review for data
collection and analysis. I plan to interview several ethnically diverse practicing physicians and
residents to learn their experiences and perspectives.
Interview Process
• The interview is confidential, no identifiers will be shared.
138

• Your participation is strictly voluntary.
• The interview will be conducted and recorded via my personal Zoom meeting
account.
• I will have a recorder available as a backup in the event of technical difficulties.
• None of the data will be directly attributed to you.
• The data will be stored in a password-protected computer and destroyed within a year
after the completed study.
Interview Questions
The range of questions will cover the following areas
• Personal journey of becoming a physician of color.
• Your perspectives on factors that contribute to underrepresentation in healthcare.
• Your experience with minority patients.
Interview Protocol
The interview protocol outlines the steps for the actual interview.
Thank you for agreeing to participate in my study. I appreciate the time that you have set
aside to answer my questions. As I mentioned when we last spoke (or emailed), the interview
should take about an hour, does that still work for you? Before we get started, I want to remind
you about this study, review the study information sheet and answer any questions you might
have about participating in this interview. I am a student at USC and I am conducting a study on
the underrepresentation of ethnic minorities in clinical medicine. I am particularly interested in
understanding how the lack of physician diversity leads to health disparities among minoritized
groups and how increasing representation is a viable approach to decreasing health disparities. I
am talking to multiple active physicians and residents to learn more about this. I am strictly
139

operating only as a researcher today. This means the nature of my questions is not designed to
evaluate, judge, or assess. My goal is to hear your story and understand your perspective.
As stated in the study information sheet I provided to you previously, this interview is
confidential. What that means is that your real name will not be shared with anyone. I will not
share them with other physicians or physician leaders within the organization. The data for this
study will be compiled into a report and while I do plan to use some of what you say as direct
quotes, none of this data will be directly attributed to you. I will use a pseudonym to protect your
confidentiality and will try my best to de-identify any of the data I gather from you. I am happy
to provide you with a copy of my final paper if you are interested.
As stated in the study information sheet, I will keep the data on a password-protected
computer and all data will be destroyed within 12 months after the study. Do you have any
questions about the study before we get started? The interview will be recorded using my
personal online Zoom meeting account. As a backup, I also have a recorder in the event we have
technical issues with the meeting platform. The recording is solely for my purposes to best
capture your perspectives and will not be shared with anyone else. May I have your permission
to record our conversation? Finally, you have the right to stop at any time, again this is strictly
voluntary.
The Problem of Practice
The underrepresentation of ethnic minorities in clinical medicine leads to health
disparities among minoritized groups.
Interview Questions
Respondent type: Active physicians
140

We will begin with questions that delve into your personal journey of becoming a
physician as a person of color.
• RQ1: What factors influence minorities to choose a career in clinical medicine?
• Conceptual framework: Bronfenbrenner (Individual, Microsystem & Mesosystem)
• Motivational framework: Bandura Self-Efficacy
• Key concept: Each individual’s personal journey as a person of color arriving at the
decision to pursue a physician career.
• personal thoughts
• influences
• challenges
• resources
Experience and behavior questions (Patton, 2002)
1. How, if at all, did being a person of color influence your career choice? (RQ 1)
2. What challenges, if any, did you overcome in pursuing a medical career? (RQ 1)
3. What resources, if any assisted you in obtaining your career goal? (RQ 1)
4. Tell me about your exposure to STEM in high school and college. (RQ 1)
5. What factors influence you to become a physician within your specialty? (RQ1)
These last set of questions explore the experience of minority patients…
• RQ2: Perception: How does representation of ethnic minorities in clinical medicine
impact health outcomes for minoritized patients?
• Conceptual framework: Bronfenbrenner (Exosystem and Macrosystem)
• Key concept: How does their unique perspective as a person of color impact patient
care for minorities?
141

• Experiences with racially aligned patients (macrosystem)
• Benefits for marginalized patients (macrosystem)
• Impact on health disparities (macrosystem)
Knowledge Question
6. As an ethnic minority physician how do you impact patient care outcomes? (RQ 2)
Experience and Behavior
7. Describe your relationship with patients that share your ethnicity and culture. (RQ 2)
8. How do minoritized patients benefit from having a diverse physician workforce? (RQ
2)
9. Share a story of how your experience as an ethnic minority physician changed a
patient’s health outcome. (RQ 2)
10. How does the provider/patient race-concordant relationship influence patient
behavior? (RQ2)
Closing Question
Opinion and Values
What other insight would you like to share about our conversation regarding the
underrepresentation of ethnic minority physicians in clinical medicine?
Closing Comments
Thank you so much for sharing your thoughts with me today! Everything that you have
shared is helpful for my study. If I find myself with a follow-up question, can I contact you by
email? If there are any websites or documents that you feel comfortable sharing with me in my
learning of this content, could you please email them to me? Again, thank you for your
willingness to participate in my study.

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Asset Metadata

Creator Roberts, Lisa Octavia (author)

Core Title An examination of ethnic minority physician representation in clinical medicine to reduce health disparities among minoritized groups

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 05/26/2023

Defense Date 04/10/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag career indicators,clinical medicine,diversity,ethnic,health disparities,minority,OAI-PMH Harvest,persons of color,physician,racial,representation,underrepresentation

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Kim, Esther (committee chair), Ahmadi, Shafiqa (committee member), Muraszewski, Alison (committee member)

Creator Email lisaweaverroberts@yahoo.com,lweaverr@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113138312

Unique identifier UC113138312

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Legacy Identifier etd-RobertsLis-11894

Document Type Dissertation

Format theses (aat)

Rights Roberts, Lisa Octavia

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