University of Southern California Dissertations and Theses

The relationship between the campus climate and under-represented students’ experiences on campus and the influences on fit, self-efficacy, and performance: a qualitative study

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The relationship between the campus climate and under-represented students’ experiences on campus and the influences on fit, self-efficacy, and performance: a qualitative study

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1
THE RELATIONSHIP BETWEEN THE CAMPUS CLIMATE AND UNDER-
REPRESENTED STUDENTS’ EXPERIENCES ON CAMPUS AND THE INFLUENCES ON
FIT, SELF-EFFICACY, AND PERFORMANCE: A QUALITATIVE STUDY

by

Christine L. Crispen

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2017

Copyright 2017 Christine Lynn Crispen

2
DEDICATION
This wouldn’t have been possible without the support of my husband, Patrick Crispen.
This journey has been a wild one and the last year has been crazy. I dedicate this to you, Patrick,
and our newest Crispen, Joseph Gibson. I also dedicate this to my Dad, Tom Bayless. I’m sorry
you aren’t here to see it in person. You would have loved the hat, Dad, and the fact that they can
now call me Doctor.

3
ACKNOWLEDGMENTS
To my third, and final chair, Dr. Patricia Tobey. Thank you for stepping up and helping
me cross this final hurdle. In addition, I thank my committee members: Dr. Wayne Combs, for
the best feedback and continued support and Drs. Ruth Chung, for also stepping up on a very
last-minute request for committee members. You have my appreciation and gratitude for helping
me reach this point.

4
Table of Contents
Dedication 2

Acknowledgments 3

List of Tables 6

Abstract 7

Chapter One: Overview of Study 9
Statement of Problem 10
Background of Problem 11
Need for Diverse Medical Education 12
Diversity in the Physician Workforce 12
Theoretical Framework 14
Purpose of Study 15
Limitations and Delimitations 16
Definitions 16
Outline of Dissertation 19

Chapter Two: Literature Review 20
Medical School Overview-The AAMC, LCME, and Processes 20
Admissions Processes 22
Affirmative Action in Medical School Admissions 23
The Importance of Diversity in Medical Education 25
Theoretical Perspectives: Critical Race Theory and Social Capital 29
Critical Race Theory 32
Campus Climate and CRT 32
Stereotype Threats 33
Racial Microaggressions 36
Effects of Racial Microaggressions 38
Who Are Underrepresented Students in Medicine? 39
Obstacles and Opportunities for URM 41
The USMLE, Residency Selection, and Underrepresented Students 42
Use of USMLE Scores for Residency Selection 45
Summary of Literature Review 47
Importance and Purpose of Study 48

Chapter Three: Methodology 50
Sample and Population 50
Instrumentation 52
Qualitative Survey 52
Variables 53
Demographic Questions 53
Conceptual Framework 54

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Data Collection 55
Analysis of Data 55
Data Analysis 55

Chapter Four: Results 57
Research Question One: Racial Microaggressions 57
Theme 1: Incidences of Racism and Microaggression 57
Theme 2: Self-Efficacy and Stereotype Threats 59
Research Question One Summary 62
Research Question Two: Campus Climate and School Fit 63
Theme 1: Attendance and Institutional Agents 63
Theme 2: Social Group Influencing Experiences and School Fit 64
Research Question Two Summary 66
Results Summary 66

Chapter Five: Discussion of Findings 68
Findings 68
Critical Race Theory and Stereotype Threats 69
Incidences of Racism and Microaggressions 70
Social Group and School Experiences and Fit 72
Institutional Agents 73
Limitations to Sample and Instrumentation 74
Delimitations 75
Implications for Practice 76
Inclusion 76
Curriculum 77
Student Programs 78
Pipeline/Post-Baccalaureate Programs 77
Admissions Practices 80
Retention/Enrollment Programs 80
Future Research 82
Conclusion 82

References 84

Appendix A: Survey 93
Appendix B: Email Solicitation of Students for Survey 96

6
LIST OF TABLES
Table 1: Gender and Class Level of Invited Students 51
Table 2: Race and Ethnicity of Invited Students 51
Table 3: Race and Ethnicity of Responding Students 52
Table 4: Theoretical Conceptual Framework 55

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ABSTRACT
This study has focused on medical students and their experiences with racism,
microaggressions, and their campus climate and how these may influence their journey and
efficacy while in medical school. Specifically, the focus has been on the differences in these
experiences between students who identify as underrepresented in medicine and those who do
not.
The current student body of the chosen medical school was invited to participate in a
mixed-methods survey, and about 10% of the students responded. Critical Race Theory, Social
Capital, and stereotype threats were the theoretical concepts that helped define the themes
derived from the qualitative responses of the survey. Three themes emerged: incidences of
racism and microaggressions; social group and school fit; and institutional agents. Also, themes
around critical race theory and stereotype threats emerged.
Findings were mixed, where some were expected, and some were unexpected. The
unexpected issues were more about the actions of the students who were on the receiving end of
racism and microaggressions as opposed to the fact that they were mistreated. The actions were
unexpected because students did not seem to understand that microaggressions were just as
pervasive and severe as overt racism, yet they did not report the smaller instances, even as they
identified them as microaggressions. Continued and more in-depth research on how they
perceive these microaggressions are influencing their education, self-efficacy, and what they
believe should be done to stop and prevent future actions is warranted so more information from
students can be explored. It would be best if students could be interviewed or focus group
discussions could occur so follow up questions, and further discussion can happen. The one
question not answered in this study was whether or not the experiences negatively harmed the

8
academic pursuits, such as failure of block systems, results of standardized tests, and success in
the clinical years, of students considered underrepresented. The limitations of the study
eliminated that opportunity.

9
CHAPTER ONE: OVERVIEW OF THE STUDY
The journey into medical school is not one that is taken lightly, nor is it one that can be
traversed without significant forethought and planning. When a person decides he plans to
become a physician, he is going to undertake years of preparation, even before he begins medical
school. During the undergraduate years, potential applicants are expected to learn the basics of
what it means to be a physician. This knowledge is gained through shadowing opportunities,
volunteer activities, and/or paid positions, such as an emergency medical technician, scribe in a
hospital, or medical assistant. Also, the prospective applicant should find time to participate in
research activities, community service, school organizations and clubs, and maintain a solid
GPA.
At the end of the first part of this journey, less than 50% of medical school applicants
matriculate into medical school (AAMC, Matriculates to Medical School, 2014). To be exact,
49,474 applicants applied to medical school and 20,343 matriculated in the academic year of
2014-15, or 41%. Going one step further, of the 20,343 applicants who matriculate, only 3,245,
or 16% are considered underrepresented in medicine (AAMC, Matriculates to Medical School,
2014). According to the 2010 U.S. Census, groups considered underrepresented are a total of
30% of the population (Humes, Jones, & Ramirez, 2011).
The process through medical school is just as difficult as the admissions process as the
medical students are now competing with the best of the best of those who matriculate and they
are also now in competition for prime residency spots after graduation. The workload is more
difficult, the volume of information is significantly increased, and the pace is faster (Dyrbye,
Thomas, Eacker, Harper, Massie, Power, Huschka, Novotny, Sloan, & Shanafelt, 2007). For
underrepresented students, additional barriers, such as financial concerns, lack of social support,

10
racial discrimination, feelings of isolation, different cultural experiences, and self-doubt may be
present and affect their overall success in medical school (Dyrbye, Thomas, Eacker, Harper, et
al., 2007; Odom, Roberts, Johnson, & Cooper, 2007).
The purpose of this study is to examine how the campus climate, racism,
microaggressions, and negative stereotype threats affect the performance of underrepresented
students while in medical school. The theoretical perspective of this study is Critical Race
Theory, which offers insights to guide efforts to transform aspects of our education that still hold
subordinate and superior racial positions in and out of the learning environment (Solorzano,
Ceja, & Yosso, 2000). Solorzano, Ceja, and Yosso (2000) describe that when a campus climate
is positive, it includes the following four elements: 1) inclusion of students, faculty, and
administration of color; 2) a curriculum that reflects experiences of people of color; 3) supportive
recruiting and retention programs for prospective students of color; and 4) a mission statement
that reinforces the commitment to diversity. This theory will lend the framework to the questions
created for the survey to the students.
Statement of the Problem
Underrepresented students face historical barriers to success in gaining admissions into
medical school, whether it is from a lack of social capital, achievement gaps, or institutional
barriers. After attaining admissions, students would expect to be on a level playing field with
their peers, since they have all overcome the difficult admissions process and are all considered
to be the brightest and best. However, in many cases, underrepresented students still hold
subordinate positions in the learning environment. They have external pressures as they attempt
to overcome affirmative action assumptions of admissions; they have familial pressures of being
the first one to graduate high school, graduate college, and gain admissions into medical school.

11
In addition, they must deal with their own internal insecurities of imposter symdrome, believing
they deserve to be in the program and believing they can succeed and graduate.
Background of the Problem
The United States is a country that has become more racially and ethnically diverse
(Cohen, Gabriel, & Terrell, 2002). The 2010 Census reports that 30% of the U.S. population is
considered underrepresented in medicine, when using metrics that are defined by the AAMC
(Humes, Jones, & Ramirez, 2011). This increase in diversity has created a greater need for a
diverse health care workforce, beginning with enrolling students into medical school. The
AAMC (2004) had identified a need for an increased diverse medical school population, even
going so far as to identify those races and ethnicities that are considered underrepresented. This
list focuses on groups of people who are born in the United States, yet, typically suffered
discrimination and bias due to skin color or ethnicity and this discrimination began early enough
that it impacted their education and their view of themselves (Underrepresentation of
Underrepresented Minorities…, 2010).
On college campuses around the United States, racial issues are becoming happening
with increasing regularity. The Journal of Blacks in Higher Education (2015) reports that several
racial incidents are occurring at the University of Missouri, Bowie State University, Howard
University, Yale University, and many other colleges. Whether these issues are overt racism or
undercurrents of racial microaggressions, gaining an understanding of not only of the campus
racial climate, but of student experiences while in college and later in medical school is
paramount to ensuring an educational environment that is welcoming to all enrolled students
(Solorzano, Ceja, & Yosso, 2000).

12
Need for Diverse Medical Education
Current and recent past court cases have eliminated the ability of admissions officers to
use race in their decision-making process when evaluating applicants (AAMC, 2004; Carlisle,
Gardner, Liu, 1998; Cohen, Gabriel, & Terrell, 2002; Green, 2004; Grumbach & Chen, 2006).
These laws have resulted in a decrease in the attendance of underrepresented students in college
and subsequently in medical school. Gurin et al. (2002) makes the argument that students gain
the richest experiences when they have meaningful interactions with diverse students and
faculty; experiences both inside and outside of the classroom. In addition to improved learning
outcomes, students believe that interactions with diverse peers enhance their medical educational
experience and give them the added confidence of being able to establish a positive rapport with
future patients (Milem, O’Brien, Miner, Bryan, Sutton, Castillo-Page, nd). In general, students,
the institution, and society benefit from increased educational diversity, which translates this
advantage into increased advantages for the health profession as well.
Diversity in the Physician Workforce
Cohen, Gabriel, and Terrell (2002) discuss four reasons behind the need for increased
diversity in the physician workforce: advancing cultural competency, increasing access to high-
quality health care services, strengthening the medical research agenda, and ensuring optimal
management of the health care system. They argue that the successful recruitment of
underrepresented into the health profession increases not only their representation, but their
influence on the educational and health process itself. The most compelling reason for diversity
in healthcare is creating a physician workforce that is culturally competent (Cohen, Gabriel, &
Terrell, 2002).

13
Cultural competence is defined as the knowledge, skills, attitudes, and behavior required
of physicians to be able to provide optimum health care services to patients from a wide variety
of cultures and backgrounds (Campbell, Sullivan, Sherman, & Magee, 2010; Cohen, Gabriel, &
Terrell, 2002). Physicians who are culturally competent must have a clear understanding of
different belief systems, cultural biases, and other factors that may influence how patients
respond to treatment and advice. This knowledge will also help guide their own practices of
providing treatment and advice (Cohen, Gabriel, & Terrell, 2002).
Rivera-Nieves and Abreu (2013) make the case for an increased diverse healthcare
workforce by arguing that first, patients often seek physicians who are from the same race/ethnic
background. In addition, it is hypothesized that underrepresented physicians would not only
work in underserved neighborhoods, but also seek to find out resolutions for health disparities
for their communities. Rivera-Nieves and Abreu (2013) and the Association of American
Medical Colleges (2004) both state that producing a workforce that is diverse and reflective of
this country’s population is not only important in terms of social equity, but it ensures the
delivery of health care that is both technically and culturally competent, which is a benefit to all.
This cultural competence increases the students’ and health care professionals’ abilities to
effectively communicate with patients and be able to provide them with the needed quality health
care (Milem et al., nd).
Smedley, Stith, and Nelson (2003) report on a study commissioned by Congress to the
Institute of Medicine (IOM) to assess the differences in the kinds and quality of healthcare
received by underrepresented minorities within the U.S. The goal of this study is to assess the
differences that are not attributable to access (ability to pay or insurance coverage); evaluate
potential biases, stereotypes, and discrimination at the provider, institutional, and health system

14
level; and, provide recommendations. Their findings show that racial disparities are present, even
after socioeconomic factors are equalized. They found that ethnic minorities, specifically African
Americans and Latinos, received unequal treatment of such diseases as cardiac disease, some
types of cancer, and HIV. The results show that these minorities have higher death rates and/or
receive less diagnostic and treatment options (Smedley, Stith, & Nelson, 2003). In addition, they
found that in certain cases, minorities are more likely to receive certain procedures that were
deemed less preferable by other physicians.
Ultimately, the need for a diverse physician workforce begins with diversity in medical
education and the admissions process. In addition, medical educators and administrators must
recognize that instances of racial microaggressions, discrimination, and questioning is still
occurring and affecting medical students who have passed the first hurdle in creating the
diversity in the workforce. The administrators must work to create a campus environment that is
truly inclusive and ready to educate the next generation of physicians.
Theoretical Framework
The theoretical perspectives are then discussed, focusing first on Critical Race Theory
and then Social Capital Theory. A thorough explanation of who underrepresented in medicine
student are, obstacles and opportunities they face, and how stereotype threats and racial
microaggressions may affect their experiences on campus, including academics. It is from these
theoretical frameworks that the survey will be created and the data will be analyzed. Solorzano,
Ceja, and Yosso (2000) offer the elements needed in a positive campus racial climate and these
elements are referenced throughout this study.

15
Purpose of the Study
This study attempts to understand how a group of medical students, students who have
overcome significant hurdles in attaining something only 50% of a group are able to attain,
experience racism on a medical campus. It attempts to understand the relationship of racism on
their self-efficacy in graduating and earning their residency of choice; it attempts to understand
how microaggressions influence how students feel about the campus and their fit on the campus
when they think back to why they accepted admissions into this school. The survey will strive to
answer the following research questions:
1. How do underrepresented medical students experience racial microaggressions and what
influence do they have on their academics and self-efficacy in their ability to succeed
through medical school?
2. Is there a relationship between a negative campus climate of racial microaggressions and
the students’ perceptions of fit and campus experience?
Critical Race Theory is the overarching theory that will be used to view and analyze the data.
The tenets of this theory are about the students’ story, why and how they experience their
education. The experiences of the oppressed, people of color, women, LGBTQ, are critical to
what is happening and is key in understanding the educational environment. It is critical to listen
to the students through their lens, rather than the lens of the normalized, dominant culture
(Delgado & Stefancic, 2012).
At the end of this study, the goal is to be able to develop programming and curriculum
that will actually benefit all students, not just the dominant group. Students will know they have
a safe place to report racial instances, both overt and covert, and understand why the covert
instances are just as debilitating to a student, if not more, because they are so subtle that one

16
questions oneself when they are uttered. Finally, it is understood that this study is focused on one
medical school in the western region of the United States. However, medicine is the
quintessential ‘good ole’ boys club’ and the hierarchy of power is clearly established. Students
and future physicians in the oppressed populations need to be given the tools and voice to be able
to break through that hierarchy and begin to truly create inclusive institutions that benefits the
diverse population of this country.
Limitations and Delimitations
The initial limitations of this study are expected to be the number of respondents to the
survey. The medical students are required to complete many evaluations and adding one more is
not going to elicit a large response. In addition to the sample size, the specifics of who responds
is variable. This is a study comparing underrepresented students to non-underrepresented
students and if there is a small number of underrepresented students completing the survey, it
may diminish the ability to compare results.
The delimitations are the fact that the initial design of this survey calls for the ability to
conduct interviews and focus groups after the survey and unfortunately, concerns with conflicts
of interest have prohibited interviews and focus groups from occurring. The data will have to be
analyzed solely from the written comments in the survey and the ability to expand on questions
and extrapolate more information is prohibited.
Definitions
• AAMC: Association of American Medical Colleges—is a not-for-profit association
representing all 144 accredited U.S. and 17 accredited Canadian medical schools;
nearly 400 major teaching hospitals and health systems, including 51 Department of

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Veterans Affairs medical centers; and 90 academic and scientific societies
(www.aamc.org).
• AMCAS: American Medical College Application Service—is the AAMC's
centralized medical school application processing service (www.aamc.org/amcas).
• Cultural Competence: one having the knowledge, skill, behavior, and attitude to
provide the best possible care to one from differing backgrounds or a set of behaviors,
attitudes, customs, policies, and resources that merge as a system to enable professionals
to effectively work in cross-cultural situations.
• Healthcare Disparities —the differences in access to or availability of facilities and
services. Health status disparities refer to the variation in rates of disease occurrence and
disabilities between socioeconomic and/or geographically defined population groups.
(National Library of Medicine: www.nlm.nih.gov/hsrinfo/diparities)
• LCME: Liaison Committee on Medical Education—is a voluntary, peer-review
process of quality assurance that determines whether the program meets established
standards (www.lcme.org).
• MCAT: Medical College Admissions Test—is a standardized, multiple-choice
examination designed to assess your problem solving, critical thinking, and knowledge
of natural, behavioral, and social science concepts and principles prerequisite to the
study of medicine (www.aamc.org/mcat).
• Medical School Curriculum —the plan of education given to medical students, years
one through four. The first two years are considered the pre-clinical or basic science
years and the second two years are the clinical years.

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• Racial Microagressions: subtle, common slights that communicate negative messages
and insults to people of color. Similar to “everyday racism” instead of more overt,
obvious racism.
• Required Clerkships —the clinical “courses” taken by third and fourth year medical
school that are required for graduation.
• Residency Match—the process by which students learn which residency (medical
specialty) they will go into after graduation from medical school.
• URM: Underrepresented in Medicine —those racial and ethnic populations that are
underrepresented in the medical profession relative to their numbers in the general
population. (www.aamc.org/initiatives/urm)
• USMLE (United States Medical Licensing Examination)—is a three-step examination
for medical licensure in the United states (www.usmle.org).
o Step 1—assesses whether one understands and can apply the concepts of the basic
sciences to the practice of medicine. Typically taken at the end of the second year
of medical school.
o Step 2 CK (Clinical Knowledge) —assesses whether you can apply medical
knowledge skills, and understanding of the clinical sciences essential for the
patient care under supervision. Typically taken in the fourth year of medical
school.
o Step 2 CS (Clinical Skills) —Like the CK exam, this exam assesses the ability to
apply the clinical sciences to patient care. However, this exam uses standardized
patients to test the medical students’ ability to gather information from patients,
perform physical exams, and communicating findings to patients and colleagues.

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The Outline of the Dissertation

The remaining three chapters are the methodology section, data analysis and theme
development, and discussion of the results. Chapter three is the methodology section of the
dissertation. This study will be a qualitative survey that will be sent to current medical students.
They will be asked for closed-ended, quantitative, demographic data as well as open-ended
qualitative questions that will allow them an opportunity to explain their experiences and
thoughts. Chapter four will be an analysis of the data and themes of the results will be explained.
The conceptual framework is established from the literature in chapter two and the questions for
each survey are developed using that framework. The themes developed are anticipated to relate
to each of the theoretical concepts.
Finally, chapter five will be the discussion of the results and provide information about
the next steps and implications for practice and future research. This discussion will be framed
using the themes and the implications for practice will be drawn from the literature and created
using the tenets of creating an inclusive, racially positive campus climate.

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CHAPTER TWO: LITERATURE REVIEW
Of the 20,343 applicants who matriculated to medical school in the academic year 2014-
2015, only 16% of them are considered underrepresented (AAMC, Matriculates to Medical
School, 2014). With the stated AAMC goal of having an enrollment of underrepresented students
that is comparable to the U.S. Census, there is still a significant gap of at least 14% when looking
at the 2010 U.S. Census report (Humes, Jones, & Ramirez, 2011). Underrepresented students
have faced historical barriers to success in gaining admission into medical school for a variety of
reasons, beginning with the lack of social capital and power and privilege and continuing with an
achievement gap faced by black/African Americans, Latinos, and Native American students.
Because of these factors, the numbers of underrepresented students enrolling into medical school
are much lower than their numbers within the population, and the disparity is growing.
This dissertation is a study of how the underrepresented medical students’ experiences
may influence their academic performance, self-efficacy, and fit during medical school when
compared to their peers. The next sections review who underrepresented students are and the
obstacles and opportunities they face. These include stereotype threats, racial microaggressions,
and possible underperformance due to these issues. Then, the theoretical section, where both
social capital theory and critical race theory will be used to frame and inform this study. Finally,
the importance of the USMLE licensure exams and how they affect residency positions for
underrepresented students is addressed.
Medical School Overview-The AAMC, LCME, and Processes
Medical schools are usually attached to larger, “home” universities around the United
States and Canada. However, they have separate, governing bodies that oversee their
accreditation and structure. Medical schools that are accredited in the U.S. offer a similar type of

21
education: the first two years are considered pre-clinical and the second two years are the clinical
years. The differences between the medical schools come in how, exactly the curriculum is
delivered, but the overall structure and delivery are the same.
The Liaison Committee on Medical Education (LCME) (LCME, 2014) accredits medical
education programs leading to the MD degree operated by universities and medical schools
geographically housed in the United States and Canada. For these programs to become
accredited and maintain accreditation, they must meet standards established by the LCME, which
require programs to demonstrate that their graduates exhibit competencies that are appropriate
for the next stage of training (i.e., an MD graduate entering into residency or a resident ready to
become an attending physician). The LCME has revised its standards from previous versions,
and the 2015 charter has established 12 standards with accompanying elements in which the
medical schools must comply. These standards address the university governance, the financial
and educational resources of the medical school, the faculty issues, clinical affiliation
requirements, the medical school leadership and scholarly activity, the medical school
administration, including curriculum and admission processes. The LCME accredits medical
schools for a period and all schools will go through reaccreditation processes periodically
(LCME, 2014).
One critical standard and competency is for medical students to graduate as culturally
competent physicians who can recognize and learn about health care disparities, biases, and be
able to develop solutions for these issues (LCME, 2014). This standard closely aligned with the
mission, vision and strategy of the Association of American Medical Colleges (AAMC) in which
medical schools will provide an education that, in addition to many other factors, develops
culturally competent physicians who are diverse and able to lead and practice in an increasingly

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diverse society (AAMC, Mission & Vision, 2004). The AAMC is the non-profit association that
represents the LCME accredited medical schools in the U.S. and Canada as well as the many
academic medical centers throughout the country. The AAMC provides services and resources to
physicians, schools, residents, students, and prospective students such as advisor and careers in
medicine, the application system, the residency application system, and the standardized entrance
exam (AAMC, 2004).
Admissions Process
All U.S. medical schools have individualized admissions processes that should comply
with the rules and regulations established by the AAMC. Similarities include general
requirements, the requirement of a secondary application, the requirement of a MCAT exam, and
interview processes. Individual processes can include how many interviews conducted, the
specifics of the admissions course requirements, and the type of letters of recommendation
needed for the files. In addition, there is some variability in the due dates of the applications.
Monroe, Quinn, Samuelson, Dunleavy, and Dowd (2013) offer an overview of the medical
school admissions process and how admissions committees select candidates. The authors
discuss how the future physician workforce is influenced and shaped by the admission process
and the subsequent medical training. Because of the increase of applicants, committees must rely
on quantifiable data to help pre-screen applicants to a manageable level. In addition, the diversity
of the applicant pool has created a need for committees to use qualitative data (non-academic) to
achieve a broader, more diverse student body (Monroe et al., 2013).
The authors also describe that the admission process is two to three stages for admission
committees (Monroe et al., 2013). The two-stage process is where applicants are reviewed based
on an application and the interview. After the interview, a committee reviews interviewed

23
applicants to determine who will be offered acceptance. The three-stage process includes a pre-
screening to invite applicants to complete secondary applications, which allows for a reduction
of the overall pool of those who are invited to interview. In either process, both academic and
non-academic data are applied in selection. Academic data include science, non-science, and
overall GPA and the MCAT scores. Nonacademic data can include personal characteristics
gleaned from the interview, demographic background (socioeconomic status, rural background,
etc.), personal statements, community service (both clinical and nonclinical experiences), and
leadership experiences. Both sets of data are important to admissions committees in their
selection of a class, and the non-academic data is becoming more important, with the advent of
the Holistic Review Process that is championed by the AAMC.
The AAMC’s Holistic Review Project is defined as a “flexible, individualized way of
assessing an applicant’s capabilities by which balanced consideration is given to experiences,
attributes, and academic metrics…and when considered in combination, how the individual
might contribute value as a medical student and future physician.” (Witzburg & Sondheimer,
2013, p. 1656). The AAMC encourages admission committees to select candidates based on
institution-specific and mission driven criteria, which does not exclude academic data but
includes non-academic measures that allow for a broader context of who the applicant is and
how they can contribute to the school and profession. Those non-academic data include
experiences such as challenges faced and resiliency to show how they have overcome challenges.
Also, medical school applicants can discuss their life experiences and how those experiences
make them stronger candidates for medical school. The successful adoption of the Holistic
Review Process is a commitment by medical schools’ admissions officers but will lead to a more
diverse physician work-force who will be leaders in a 21st-century health care field.

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Affirmative Action in Medical School Admissions. Admissions practices, both
undergraduate and medical school share many similarities in selectivity, the use of GPA and
standardized exams and the goal of enrolling the best candidate for their institutions. Bowen,
Kurzweil, and Tobin (2005) review the long-term consequences of considering race in
admissions practices. They discussed the concerns of the public in being “fair” in admissions
practices and how schools should reward applicants who achieved the highest numbers (GPA
and test scores). However, do these numbers reveal how graduates will contribute to society and
what life circumstances faced by applicants as they worked toward achieving these numbers?
Bowen, Kurzweil, and Tobin (2005) state that fairness is when applicants are judged on a
consistent set of criteria, not that particular segments of criteria must always be weighted heavier
than others. Many underrepresented students have different life circumstances that affected their
scores and have no reflection on their ability to succeed in college. Admissions officers must not
look at a side-by-side comparison of students and determine who has the best numbers. The goal
is for committees to review the individual applicants independently and as part of the group and
determine what factors are most important and how these people can contribute to the institution
as well as society.
When making admissions decisions, the use of race is an important factor because
without this deliberation, the overall goal of increasing diversity may be damaged and
consideration accounts toward meeting objectives often central to institutions’ mission and goals
(Bowen, Kurzweil, & Tobin, 2005; Cohen, 2003). The use of race in medical school admissions
must be continued until such time “students from all racial and ethnic backgrounds emerge from
the educational pipeline with an equivalent range of academic credentials…medical schools
cannot meet their societal obligations…” (Cohen, 2003, p. 1143). The societal obligations consist

25
of producing a culturally competent workforce who is prepared to meet the needs of a growing
diverse society. The argument Cohen is making is in favor of equitable admissions to result in
excellent educational experiences for medical students.
Opponents of affirmative action in medical school admissions have argued that to allow
for racial and ethnic factors to be considered, the academic excellence is diminished. While no
one is arguing for accepting applicants who have a subpar academic record, academics is not the
sole factor in determining what makes a strong applicant. Cohen (2003) states that the
underrepresented candidates who matriculated to medical school, they graduate at comparable
rates to their non-underrepresented counterparts. They are successful in classes, clinic, and all
required standardized exams required throughout their career. Medical school admissions
committees are showing that they can select a diverse class while maintaining high academic
standards and produce competent, compassionate, and culturally competent physicians into the
workforce. Cohen (2003) concludes that the use of race-conscious decision-making does not
mean a diminished bar of excellence in the product, in fact, he argues just the opposite.
The Importance of Diversity in Medical Education. The Association of American Medical
Colleges (AAMC) has a stated mission of working to promote a culturally competent, diverse
and prepared health workforce leading to health and health equality (AAMC, 2012). This
mission is critical because the United States has increasingly become more diverse from a variety
of racial and ethnic backgrounds (Cohen, Gabirel, & Terrell, 2002; Sullivan & Mittman, 2010).
The need for diversity in the health field is as important as the need for diversity in education in
general. Gurin, Dey, Hurtado, & Gurin (2002) explore the relationship between students’
experiences with diverse peers in college and the improvement of educational outcomes. They

26
argue that when students experience diversity in a meaningful way their learning outcomes are
improved, and they become more active citizens able to work in a global society.
Nivet (2010) continues by explaining that for physicians to be able to provide optimal care,
physicians must be able to understand the cultural differences and indigenous belief systems of
our diverse population and how their own biases affect their ability to provide this care. He
argues that to provide this culturally competent health care, physicians must be educated in a
diverse setting. Nivet (2010) defines cultural competence as one having the knowledge, skill,
behavior, and attitude to provide the best possible care to one from differing backgrounds. The
Sullivan Commission (2004) defines cultural competence as a set of behaviors, attitudes,
customs, policies, and resources that merge as a system to enable professionals to effectively
work in cross-cultural situations.
Rivera-Nieves and Abreu (2013) and Sullivan and Mittman (2010) make a case for an
increased diverse healthcare workforce by arguing that first, patients often seek physicians who
are from the same race/ethnic background. In addition, it is hypothesized that underrepresented
physicians would not only work in underserved neighborhoods but also seek to find out
resolutions for health disparities for their communities. Rivera-Nieves and Abreu (2013) and the
Association of American Medical Colleges (2004) both state that producing a workforce that is
diverse and reflective of this country’s population is not only important in terms of social equity,
but it ensures the delivery of health care that is both technically and culturally competent, which
is a benefit to all. This cultural competence increases the students’ and health care professionals’
abilities to effectively communicate with patients and be able to provide them with the needed
quality health care (Milem, O’Brien, Miner, Bryan, Sutton, Castillo-Page, & Schoolcraft, nd).

27
In 2004, the Sullivan Commission on Diversity in the Healthcare Workforce was charged
with helping develop strategies to increase diversity in the health professions and attempt to
reduce health disparities among the country’s underserved and underrepresented population. In
the report, the commission states that health care professionals lack resemblance to the diverse
populations they serve leaves patients feeling excluded by the system and the fact that they have
not kept up with the changing demographics of the country may be a greater cause of health
disparities than the lack of insurance. They continue to state that if the demographics of future
physicians and other providers do not resemble that of the population, as much as one-third of
the nation’s population is at risk for continued access and outcome problems (Sullivan, 2004).
The recommendations put forth by the Sullivan Commission (2004) begin with the
premise that health care must be provided by well-trained, qualified, and culturally competent
professionals that mirror the population it serves. The Commission developed the
recommendations with three underlying principles: 1) health professional schools must exam
their practices and review their policies of admission and education; 2) improvements must be
made in the K-12 educational system as well as the health professional educational sectors; and
3) commitment to change must be at the highest level.
The findings and recommendation of the Sullivan Commission (2004) begin with the
rationale for increasing diversity in the health profession. They posit that not only
underrepresented populations will benefit from this increased diversity and believe that the entire
population will benefit from a workforce that is “culturally sensitive and focused on patient care”
(Sullivan, 2004, p. 3). The principles underlying this rationale are: diversity is critical to
increasing cultural competence, which leads to improved health care; improved patient
satisfaction; underrepresented providers tend to practice in underserved areas, thus improving

28
access and quality care; and social justice is served by the improved quality and access to care to
formerly underserved population and areas (Sullivan, 2004).
The recommendations put forth by the Sullivan Commission (2004) include strategies for
increasing diversity and cultural competence in the healthcare workforce; the need for public and
private funding entities to increase financing for research about health care disparities; and
promotion of training in diversity and cultural competence for those already in the healthcare
workforce. The Commission also addresses the need for a health professions pipeline for
underrepresented students. They recommend that health professions schools and organizations
partner with public school systems to provide students with learning opportunities for academic
enrichment in the sciences and provide public awareness campaigns to encourage
underrepresented students to pursue a career in the health professions. They continue with a
discussion of a need for undergraduate programs to provide a bridge program that enables
community college graduates to successfully transfer to four-year universities and create support
services that include mentoring, test-taking skills, counseling on the application procedure, and
interviewing skills (Sullivan, 2004).
Finally, the Sullivan Commission (2004) discusses the need for help with financing a
health professions education and accountability, where federal and state agencies establish
guidelines, standards, and regulations for increasing diversity and cultural competence within the
health professions. This recommendation includes more legislation to strengthen institutions that
serve underrepresented populations. The Commission believes that for the barrier of financing an
education, more loan forgiveness programs, scholarships, and tuition reimbursement strategies
should be established as well as additional support for diversity programs within the National
Health Service Corps and the Public Health Service Act.

29
The Sullivan Commission (2004) has a goal of increasing diversity in the health
professions. They seek to incorporate more people from varying backgrounds to be included,
increase excellence in the health care system, and all Americans are included in a health care
system where they receive the high level of care and access.
The admissions process for medical school is rigorous and intensive and many times as
subjective as objective. The Holistic Review commission and affirmative action are similar in
that they both advocate looking at the whole person and not necessarily comparing that person to
another candidate, but reviewing him as a singular person with a story to determine if he fits in
the medical school to which he has applied. When that story is taken as a stand-alone and
holistically reviewed for not only the objective academics completed, but the narrative that
defines how this student succeeded, the necessary diversity of a class is inherent. All applicants
are different. They all come from different places in life: many are wealthy, many are poor, first-
generation students, and most fall somewhere in between. They all have something to offer, and
all should have an equitable opportunity to shine through this process.
Theoretical Perspectives: Critical Race Theory and Social Capital
When thinking about why underrepresented students are not as successful in attainment
as the dominant student with whom they compete, one must first review privilege, power, social
and cultural capital of all parties involved. Johnson (2006) posits that privilege and power exist
because of societal systems and one’s participation within them. He has identified three key
characteristics of privilege and defines how they perpetuate the privilege and power of the
dominant groups. One is dominance, which is when a privileged group dominates a system and
members of the dominant group occupy the positions of power; examples are male, white,
heterosexual, and able-bodied dominance. The second characteristic, identity with privilege,

30
means that the privileged group is generally the standard by which the rest of society is
measured, the norm. Moreover, the third characteristic is privilege at the center, because society
identifies with the privileged, it is the path of least resistance to focus on them as the norm
(Johnson, 2006). Because it is easiest for society to follow what is considered the norm, many
groups of underrepresented minority students are left out of the educational system.
Freire (1993) suggests that oppressors use education more for their benefit than for those who are
receiving the education, which is to continue the overall dominance and oppression. Moreover,
like Ruby Payne’s idea of ‘helping’ those overcome poverty, the oppressors believe that people
can change their incompetent and lazy patterns by changing their thought process (Gorski, 2008).
The oppressed just need to be integrated and assimilated into the better, healthy society. Freire
(1993), Gorski (2008), and Johnson (2006) all argue that underserved are not people living on
the outside of society, but are indeed part of society. They just need the structure of society and
institutions to transform so they can become a full part. Without the institutional transformation,
underrepresented students are considered lacking and at a deficit from those within the dominant
groups.
Much like Gorski (2008) explained how Payne used a ‘deficit theory’ Johnson (2006)
says the dominant group uses the ‘Blame the victim’ approach, which is when one acknowledges
that bad things have occurred but blames the victim for those things occurring. “If they worked
harder, went to school…did this…did that…” they would not face these problems. “She asked
for it…she wasn’t womanly enough…she was too emotional…” No matter the situation, the
victim is blamed. This allows the dominant to remain invisible and untouched by the situation.
Ovink and Veazey (2011) researched underrepresented students pursuing degrees in the science
and biomedical fields. They conducted a study of the Biology Undergraduate Scholars Program

31
(BUSP) at UC Davis, which has a record of attracting and retaining high achieving
underrepresented students in the biological sciences major. This program also helps students
acquire the necessary knowledge and skills for success in the science and biomedical fields. The
goal of their research is to show that efforts toward expanding “habitus” and supplementing
social and cultural capital complement the gains achieved by also helping underrepresented
students succeed academically (Ovink & Veazey, 2011, p. 372). They posit that focusing solely
on academics in insufficient in addressing inequities in education for underrepresented students
in the sciences.
Underrepresented students can gain the necessary social and cultural capital to not only
attain a baccalaureate degree but also begin working toward the next step of their education. As
argued by Stanton-Salazar (1997) children need to have social capital and networks to
successfully navigate and understand the structure of the educational system. These networks can
empower a youth’s choices in education and give the information necessary for college
attainment. Many middle-class children have this social capital by way of institutional agents
such as teachers, clergy, social workers, parents, friends of parents, and peers. In addition,
teachers see that these children have this capital and automatically assume they have talent and
extend higher expectations as well as encouragement and support. These children gain resources
and privilege not afforded to children without this capital.
Stanton-Salazar (1997) argues that the effective development of students who are socio-
economically disadvantaged depends upon their ability to move across different socio-cultural
worlds. They must not only be able to decode mainstream educational settings but must be able
to actively participate in those settings. The conclusion of the Ovink and Veazey (2011) study
shows that underrepresented students can begin to overcome institutional barriers they face by

32
targeted interventions to help students begin decoding those educational barriers. The need for
institutional change is imperative, however, because even when underrepresented students can
cross cultural borders, they are still coping as an oppressed member of the dominant society
(Stanton-Salazar, 1997).
Critical Race Theory
Critical race theory began as a movement of activists studying the relationship between
race, racism, and power (Delgado & Stefancic, 2012). This theory posits that the traditional
equality, color-blind expressions can correct only the overt forms of racism and that the advances
in mitigating racism have only occurred to promote the more dominant group. A major tenet of
this theory is that the experiences of the oppressed, people of color, women, LGBTQ, are critical
to what is happening to them. This theory has recently been used to understand what is
happening in the educational environment and in order to truly understand what is happening, it
is critical to listen to them through their lens, rather than the lens of what is seen as the
normalized, dominant culture (Delgado & Stefancic, 2012; Tate, 1997). Tate (1997) continues
that people of color speak from experiences defined by racism and from this perspective, the
reality of a person of color is constructed by the stories and experiences of the individual.
Delgado and Stefancic (2012) explain critical race theory as allowing one to define their reality
with the importance of story, counterstory, and experience.
Delgado (1989) posited four reasons for the use of experiences and stories of oppressed
people in the creation of this theory. One is that a person’s reality is socially constructed; two
stories are a powerful way of adjusting ways of thinking; three is the community-building
function, and four, stories provide members of the non-dominant group mental self-preservation.
It is these four reasons of Delgado that provide the onus for using this theory in this study.

33
Campus Climate and CRT. Students perceptions of the campus and how they believe
they belong on that campus can affect the students’ self-efficacy and their academic performance
(Edman & Brazil, 2007). The sense of community and feelings of belongingness translates into
retention, greater academic performance, and an overall successful transition into the collegiate
environment. Underrepresented students of color face a campus climate that is often very
different than what is deemed best for success. Negative campus cultures, stereotype threats, and
racial microaggressions are often in place of inclusion, a culturally competent curriculum,
supportive programs of recruitment and retention, and a mission of a commitment to diversity
(Solorzano, Ceja, & Yosso, 2000). According to a study of racial microaggressions and campus
racial climates, Solorzano, Ceja, and Yosso (2000) spoke with underrepresented students who
often felt invisible, not understood, faced low expectations by faculty, their own self-doubt
brought on by faculty and administrators in their school, and the ‘token’ person of color in the
class.
Stereotype Threats. What are the experiences of students who are in the same
classroom, with the same teacher, and learning the same material? How is it that the experiences
of students of color and women can be so different from other students who are in the same
situation? The theory behind stereotype threats assumes that students who are successful in
school have developed an identity with the school and its subdomains, yet societal pressures and
negative stereotypes threaten the belief system of students of color to the point where their
academics suffer, and these students suffer a disconnect with the school (Steele, 1997). The
assumption behind the theory is that one of the factors behind success in school is positive
feelings depend on achievement and the feeling that one belongs in that environment (Steele,

34
1997). Conversely, if these positive feelings do not develop if the feelings of belonging in the
school environment are not present, what happens to students and their achievement in school?
Appel and Kronberger (2012) completed a review on how stereotype threats not only threaten
marginalized groups’ ability to take tests but how it also affects their overall learning. Appel and
Kronberger’s (2012) literature review demonstrates the influence stereotype threats has on the
academics before standardized test taking. Their review explains that individuals experiencing
stereotype threats had trouble encoding, summarizing and evaluating information, all of which
lead to lower ability and competence levels, resulting in poorer performance (Appel &
Krongerberger, 2012). The standard definition of stereotype threat, which is said to affect test-
taking abilities, is the final stage of the threat.
The societal structure experienced by particular groups of students: socioeconomic
barriers, segregation, and historical and current cultural barriers, that specifically include
inadequate resources, few role models, and inadequate academic preparation, make it more
difficult for certain groups of students to form a positive identity with the school and the
necessary feelings of belonging to be successful (Schmader, 2010; Steele, 1997). Schmader
(2010) continues by stating that students who are aware of the stereotype are extra vigilant in
working to avoid confirming the stereotype, yet usually expend more cognitive energy on this
avoidance and ultimately do poor on the task. The same people threatened by these stereotypes
are many times those most interested in doing well in their scholastic domain (Schmader, 2010).
Toro and Crystal (2011) researched stereotype threats for underrepresented students in medical
school. They used a modified survey to measure students’ perceived barriers to their success in
medical school as well as control and non-control study groups. The experimental group was
given a statement about the stereotypical threats that underrepresented students face; specifically,

35
a lower GPA and MCAT score in comparison to their white student counterparts. In addition,
they were given information about affirmative action bans in various states and how the numbers
of underrepresented student enrollment into medical school has dropped significantly. The main
finding of this study was that underrepresented students expected to experience stereotype threats
that physicians were “white, Euro-American, males” and had the right to earn the status of doctor
(Toro & Crystal, 2011, p. 18).
Solorzano, Ceja, and Yosso (2000) study how stereotype threats can affect the
performance of African American students in the academic environment, studying the links
between racial stereotypes, racial microaggressions, campus climate, and academic performance.
The participants in this study were African American students (34: 18 females and 16 males)
who attended elite, Research I institutions (two public and one private) in the United States.
They participated in 10 focus groups on each campus with themes covering the types of racial
discrimination experienced on campus; students’ response; the effect of the discrimination to the
students; the benefits of having more African American students on campus; whether there has
been improvement in the racial climate on campus; and if the participants would recommend the
institution to other African American students (Solorzano, Ceja, & Yosso, 2000).
The overall results of this study were that students believed there was a tense racial
climate both inside and outside the classroom (Solorzano, Ceja, & Yosso, 2000). The students
felt “invisible” inside the classroom, which in turn increased doubts brought about by stereotype
threats (Solorzano, Ceja, & Yosso, 2000, p. 65). Students continued to express that their white
peers believed they were admitted into the institution under affirmative action rather than their
individual abilities and they felt uncomfortable in general on the campus and felt discouraged
from taking advantage of services offered by the institution (Solorzano, Ceja, & Yosso, 2000).

36
Racial Microaggressions
Racial microaggressions are subtle, common slights that communicate negative messages
and insults to people of color (Solorzano, Ceja, & Yosso, 2000; Sue, Capodilupo, et al., 2007).
These slights are common enough that many perpetrators may not realize they have engaged in
these types of communications. Racial microaggressions may be categorized into three types:
microassault, microinsult, and microinvalidation. President Clinton’s 1998 Race Advisory Board
concluded that racial inequalities are so ingrained in the American society, that many white
people are not aware of their inherent advantages and how attitudes and beliefs may discriminate
against persons of color. This lack of awareness has not improved, to the point where in 2015,
the University of Missouri students of color have protested many of the activities occurring on
their campus. They have been subject to racial slurs and incidents. When a group of students
asked the president how he defined “systematic oppression”, he responded with “…systematic
oppression is because you don’t believe that you have the equal opportunity for success — ”.
(Washington Post, Svrluga, 2015). This answer is an example of privilege and a lack of will to
understand how racism, whether it is delivered overtly or in the form of microaggressions, is still
rampant on many college campuses around this country.
Sue, Capodlipup, et al. (2007) describe the three types of microaggressions in more
detail. Microassault is most similar to racism conducted at the individual level, usually conscious
and deliberate. Microinsult is more subtle, with hidden messages to persons of color. These
insults can be both verbal and non-verbal, conveying a message that persons of color are
unimportant and their contributions are unimportant. Finally, microinvalidation tends to exclude
(invalidate) the feelings or experiences of persons of color. An example is when people say they

37
“don’t see color” or “we’re all human beings” the experiences of persons of color is negated
(Sue, Capodlipuo, et al., 2007, p. 274).
Sue, Capodlipuo, et al. (2007) continue to explain that racial microaggressions are
powerful because many times they are small acts that are easily explained away by a seemingly
rational and nonbiased explanation and the recipient is left questioning whether or not it
occurred. The researchers state that most people of color would prefer actual, overt acts of
racism over microaggressions as they are easier to manage.
Beagan (2003) studied everyday racism against students who are in medical school.
Everyday racism is defined similarly to racial microaggressions in that the racial slights against
minority groups are inconsequential, seen as normal, and not necessarily intended to be insulting.
They are in fact everyday actions that may seem minor and trivial, almost not worth addressing,
but when taken in the totality, cause those to whom they are addressed to feel slighted as if they
do not belong, and confused (Beagan, 2003).
The questions addressed by Beagan’s (2003) study concern how social differences of race
and culture are experienced by medical students in Canada and the ways social interactions may
perpetuate inequalities. The methods of her study are surveys and interviews of self-selected
third-year medical students, who are close to the end of their third year (the required clinical
rotations in medical school). The researcher surveyed and interviewed two cohorts of third-year
students about three years apart and the cohort was selected because they will have had close to a
full year of clinical training, which would have put them in close contact with physicians and
patients. The second cohort of students was interviewed to determine whether a new curriculum
that had been put into place had any effect on student awareness of issues (Beagan, 2003).

38
In the interviews of students, it was found that overt acts of racism were not apparent in
medical school. Many students even argued that racism was not an issue because the school
seemed racially diverse and the community was multicultural (Beagan, 2003). In fact, many of
the monolingual students commented that students who spoke multiple languages had an
advantage of being able to better communicate with patients, sometimes being used as translators
in clinical settings. However, these same students did not see the parallel of how being white
afforded them the same privilege of looking like they belong as a physician, as members of the
dominant culture and assumptions of what physicians do and should look like (Beagan, 2003).
Students who are racial minorities of this institution do feel marginalized, many feel rejected,
and many believe there is a passive tolerance of racism towards them because of the slight,
everyday racist occurrences. A very telling quote from a marginalized student is that “If you’ve
never experienced it [racism] before, you will not understand why it’s bothersome.” (p. 857).
This student believes she does not fit into this medical school.
Beagan (2003) concludes that micro level racism such as everyday racism, or
microaggression, are challenging to deal with at the institutional level. Students, especially those
who are faced with major power differentials with clinical faculty, and others who experience it
often believe it is not ‘worth’ getting into, and many worries that it will affect them in the long
term. Unfortunately, the slights that accumulate over the long term have an overall negative
impact on the recipient (Beagan, 2003).
Effects of Racial Microaggression. There is a significant effect of racial
microaggression on students of color on college campuses (Solorzano, Ceja, & Yosso, 2000).
These effects range from feelings of frustration and doubt to outright academic struggles.
Students found it harder to participate in class, and many felt helpless to respond or make any

39
positive contributions in the academic setting. These microaggressions are pushing students to
drop classes, change majors, or leave an institution to attend one friendlier to students of color.
Another effect is being the spokesperson for that particular race/ethnicity (Solorzano, Ceja, &
Yosso, 2000). Students in this study explained that whenever a discussion occurred regarding
their race/ethnicity, and they happened to be one of a very few of that group, they were generally
called upon to represent that perspective. This expectation became old and tiring very quickly to
students (Solorzano, Ceja, & Yosso, 2000).
This section focused on the theoretical aspects of the study: critical race theory, social
capital, stereotype threats, and racial microaggressions. They are distinct concepts that have been
woven together to provide the significance of this study: students of color need to be able to tell a
story through their lens of life; that traditional, color-blind programs are not universally positive.
In fact, in many cases, color-blind programs have only enhanced racial oppressions and
advanced the dominant group, even those that are well-intended (Delgado & Stefancic, 2012).
When students belong to the non-dominant group are overlooked or are only looked at as the sole
voice for that group, they lose interest, and their experiences become negative and harmful. This
study hopes to bring out the “everyday racism” that is hidden, but apparent in many institutions;
face these microaggressions and create the environment that is inclusive for all students (Beagan,
2003).
Who are Underrepresented Students in Medicine?
The United States is a country that has become more racially and ethnically diverse
(Cohen, Gabriel, & Terrell, 2002; Sullivan & Mittman, 2010). This increase in diversity has
created a greater need for a diverse health care workforce, beginning with enrolling students into
medical school. The AAMC (2004) had identified a need for an increased diverse medical school

40
population, even going so far as to identify those races and ethnicities that are considered
underrepresented. The specific races and ethnicities categorized as URM are African Americans,
Mexican-American, Native American, and mainland Puerto Ricans (AAMC, 2004; Sullivan &
Mittman, 2010). In California, some citizens of Asian/Pacific Islander descent, including those
who are Samoan, Cambodian, and Hmong/Laotian are also considered underrepresented in
medicine (Grumbach, Odom, Moreno, Chen, Vercammen-Grandjean, & Mertz, 2008). This
group of people makes up less than a half of a percent of physicians in the state of California.
This list focuses on groups of people who are born in the United States, yet, typically suffered
discrimination and bias due to skin color or ethnicity and this discrimination began early enough
that it impacted their education and their view of themselves (Merchant & Omary, 2010;
Sullivan & Mittman, 2010). This definition accomplished three objectives established by the
AAMC: 1) Allow for inclusion and exclusion of underrepresented groups based on
demographics of society and the profession. 2) A focus on the local perspective on
underrepresentation. 3) Data collection and reporting on a broad range of racial and ethnic self-
descriptions (AAMC, 2004).
Events initiated through the voting polls and upheld by the Supreme Court have affected
the numbers of underrepresented students enrolling into medical school. The first, in 1995, the
Regents of the University California system decided to ban the use of race, ethnicity, and gender
based admissions; the second was in 1996 when the US Supreme Court upheld a District Court
of Appeals that eliminated racial preferences in Texas schools (Carlisle, Gardner, & Liu, 1998).
Finally, in 1996, the California voters disallowed the use of race, ethnicity and gender
preferences in all state offices. Carlisle, Gardner, and Liu (1998) report that any gains made

41
toward increasing diversity in medical school admissions had begun decreasing due to these
types of changes, particularly at public institutions.
Obstacles and Opportunities for URM
Beyond the achievement of gaining admission into medical school, URM students face
additional barriers and constraints in their learning environment. Odom, Roberts, Johnson, and
Cooper (2007) explored the perceived barriers and opportunities of underrepresented students
enrolled in various medical schools. This study is different because the researchers worked
directly with students as opposed to asking various administrators in the medical schools. They
conducted focus groups with students who were medical student members of the Student
National Medical Association (SNMA), which is the oldest and largest student organization
dedicated to the education of minority pre-health and medical students (Odom et al., 2007). The
students were asked about personal goals, experiences, and needs about their future professional
practice. They were also invited to define what success meant to them. The responses were
categorized into a set of themes.
The first broad category, success, had seven themes including financial,
professional/academic, happiness, identity, self-determination, balance, and service (Odom et al.,
2007). The students qualified some of these answers by saying that financial success was more
about fulfilling their survival needs rather than just gaining individual wealth. The second
category, facilitators to success, consisted of scholarships, support, professional exposure, and
personal experience. Many students noted that the respective schools’ offices of minority
affairs/diversity provided support, information about scholarships, and academic efforts. Of note,
students indicated a need for minority role models to provide support (Odom et al., 2007).

42
Finally, the last category, inhibitors to success, was addressed. The domains of the
inhibitors to medical student success include a lack of support, discrimination, lack of cultural
representation, testing, self-doubt/stereotype threats, and financial factors (Odom et al., 2007).
While the family was considered a facilitator to success, in some instances, it is also seen as a
barrier. Often family members are unable to neither understand the medical school experience
nor offer any financial support. The participants in the study also reported the difficulty with the
standardized testing that is common in medical school assessments and felt a lack of experience
with the methods of evaluation typical of the medical school environment.
Another, significant finding in this study is the feelings of inferiority and self-doubt of
the minority medical students (Odom et al., 2007). This doubt is exacerbated by what they
perceive as their token status as one of the few members of their racial or ethnic group. This is
continued by the lack of understanding by medical students’ peers, the faculty and
administration’s lack of understanding of admissions policies and possibly affirmative action
programs (Odom et al., 2007). The importance of inclusiveness and of having a diverse medical
education is many times lost in the negative stereotypes perpetuated.
The USMLE, Residency Selection, and Underrepresented Students
The United States Medical Licensing Examination (USMLE) is a three-step examination
for medical licensure in the United States which assesses the examinee’s ability to apply
knowledge, concepts, and principles as well as demonstrating fundamental patient-centered skills
that are critical in effective patient care (NBME, 2014). Step 1 assesses the examinee’s
understanding and ability to apply relevant concepts that are basic to the practice of medicine. It
assesses the mastery of the foundations for the safe and competent practice of medicine as well
as the scientific principles required. Medical students usually take this exam at the end of their

43
second year. Step 2 consists of two components: clinical skills (CS) and clinical knowledge
(CK). This exam assesses the examinee’s ability to apply medical knowledge, skills, and
understanding of clinical science essential for providing medical care under supervision. Step 2
CS is a practical exam and examinees are assessed on their data-gathering and communication
skills by the standardized patients as well as their ability to complete the appropriate patient
notes. Step 2 CK is a computer-based, multiple-choice exam. Fourth-year medical students
typically take both components of Step 2 before they graduate medical school, and usually
before they apply to medical residencies. Step 3, typically taken at the end of residency, before
the resident graduates to become an independent physician, assesses the examinee’s
understanding of biomedical and clinical science essential for the unsupervised practice of
medicine (NBME, 2014).
The pass rate for USMLE Step 1 for first-time test-takers in 2013 was 95% and for
repeaters was 72% (NBME, 2014). Andriole and Jeffe (2012) completed a national study of all
matriculated medical students between academic years 1993-1994 and 2000-2001, specifically
looking at the 6.2% of those who failed initially Step 1. The goal of the researchers of this study
was to gain an understanding of the factors associated with taking and passing the Step 2 exam
after initially failing Step 1. The researchers believe this understanding can inform medical
schools of potential difficulties students may face moving forward from the Step 1 exam.
Of the 6,594 students in their sample of students initially failing Step 1, 30.4% failed their first
run at Step 2 CK, and 9.2% did not even attempt to take Step 2 CK. Of the students in their
study, 90.3% ultimately graduated from medical school, including 7.7% of those who never tried
to take Step 2 CK and 96.7% of those who initially failed Step 2 CK. The characteristics of the
students in the Andriole and Jeffe (2012) study show that the majority who initially failed Step 1

44
and subsequently Step 2CK are underrepresented. Specifically, in the sample used for this study,
55% of the matriculates were women, and 62.9% were non-white. Andriole and Jeffe (2012)
found that the breakdown of first-time Step 1 passing rate for students enrolled during this time
was: 93.4% white, 86.8% Asian, 77.5% Hispanic, and 58.2% African American. The passing
rate for Step 2 for this cohort of students was: 96.3% white, 87.6% Asian, 86.9% Hispanic, and
71.5% African American.
McDougle, Mavis, Jeffe, Roberts, Ephgrave, Hagemen, Lypson, Thomas, and Andriole
(2013) studies the professional outcomes of graduates who failed the USMLE Step 1 on the first
attempt. They studied a cohort of graduates from six Midwestern medical schools. They
compared the socio-demographic characteristics, other academic performance, and ultimate
career paths of the graduates who did and did not pass Step 1 the first time (McDougle et al.,
2013). In addition to the basic demographic information the researchers gathered, they also
sought information regarding intent to practice medicine in underserved areas from graduation
questionnaires administered through the AAMC.
The results of the McDougle et al. (2013) study showed that only 2.5% of first-time test
takers failed Step 1, 53% of this group went on to become primary care physicians who reported
intent to practice in an underserved area. Also, they found that those who failed were more likely
to take five or more years to graduate medical school and were considered underrepresented
minorities (McDougle et al., 2013). Other characteristics of those who failed are first generation
college students, having a lower socioeconomic means, and being older at medical school
matriculation and graduation. These students also had lower subsequent USMLE test scores.

45
Use of USMLE Scores for Residency Selection
Historically, it is argued that underrepresented students do not perform as well on all
standardized tests as do their white student counterparts and these tests are inherently unfair to
the underrepresented student population (Edmond, Deschenes, Eckler, & Wenzel, 2001; Fleming
& Garcia, 1998). As mentioned in the previous sections, the scores of the USMLE Step 1 are
heavily used in the selection of residency applicants and yet, this test is one that many times
adversely affects the student body that can increase the diversity of the medical profession
(Lieberman, Ainsworth, Asimakis, Thomas, Cain, Mancuso, Rabek, Zhang, & Frye, 2010).
Green, Jones, and Thomas (2009) conducted a study to gain access to residency program
directors’ opinions about the relative importance of USMLE scores in their selection criteria. The
results of this survey revealed that the top academic criteria used in selection were clinically
based except the USMLE Step 1 score, which rated consistently high across all specialties.
Other selection criteria included academics other than USMLE scores, specifically clerkship
grades, extracurricular activities, supporting information, and issues of concern (Green, Jones, &
Thomas, 2009). The researchers found the USMLE Step 1 was objective enough to substitute for
specific clinical grades. McDougle et al. (2013) and Andriole and Jeffe (2012) and NRMP all
found that 84% of residency program directors who required students to submit Step 1 scores for
their residency application reported that they did not consider interviewing applicants who failed
Step 1.
There are conflicting arguments as to whether the use of the USMLE exams is a viable
selection criterion for residency applicants. McGahie, Cohen, and Wayne (2011) in direct
response to the Green (2009) study studied the validity of the USMLE Step 1 and Step 2 scores
as selection criteria for medical residencies. Their study found that many experts believe that the

46
USMLE should not be used as one of the criteria and that there was little correlation to the
necessary clinical components needed for successful practice. The exams were designed as a
mechanism toward licensure decisions, not resident selection. In rebuttal to this argument,
Dillon, Clauser, and Melnick (2011) argued that if the scores of the USMLE exams are
correlated to a mastery of applied basic and clinical science knowledge, and that those who have
passed the exams have gained a foundation in these domains, then the use of the scores in
residency selection is reasonable. They continue that the USMLE scores provide meaningful
information to residency directors and allow for a comparison of an individual from a broad
range of backgrounds and diverse educational experiences.
In a study determining if the use of the Step 1 scores of the USMLE to grant interviews
was racially biased, Edmond et al. (2001) surveyed the country’s Internal Medicine Residency
Directors to determine whether or not they used the scores of Step 1 in granting interviews and
whether or not they had a minimum cut off of the score. They chose Internal Medicine as a
starting point of residencies because it is one of the larger program specialties and they believed
they would obtain a good cross section of applicants from many medical schools. The
researchers hypothesized that African Americans would not be offered interviews and as a result,
their residency selection would also be negatively impacted.
The results of this study revealed that 92% of the 259 programs from which they received
responses used the USMLE Step 1 score in the decision to offer interviews and close to 60% had
a minimum score requirement (Edmond et al., 2001). They also computed the mean Step 1
scores for both African American students (n=47) and non-African American students (n=626)
and found that for this particular cohort of students, the African American students’ mean score
was 200 and non-African American students’ score was 216. For the programs using a minimum

47
score cut point, the researchers determined that an African American applicant was three to six
times less likely to be offered an interview than a non-African American applicant (Edmond et
al., 2001). In the conclusion of this study, the researchers stated in that using their data from this
study, setting up a minimum score to grant interviews would “preferentially exclude African
American students” with the result being a less diverse program (p. 1256).
Summary of Literature Review
This literature review began with an overview of medical school governance, admissions
practices, and general processes. This overview focused on the LCME, AAMC, and how these
bodies help to accredit and regulate the medical education that occurs in the United States. A
historical perspective of how medical education today came to be from and how these results
continue to have consequences for the lack of diversity in medical education today. It also
included both sides of the argument of affirmative action in the admissions process and a brief
discussion of the results of many legislative practices that are in place today, which is a growing
gap of enrollment into medical school for underrepresented students and a widening gap of
health care disparities for underrepresented communities (AAMC, 2004; Carlisle, Gardner, &
Liu, 1998; Cohen, 2003; Cohen, Gabriel, Terrell, 2002; Gurin, Dey, Hurtado, & Gurin, 2002;
Merchant & Omary, M 2010; Moy, Dayton, & Clancy, 2005).
The final sections of the literature review focused on the potential consequences that
negative experiences can have on students. These consequences include poor standardized test
scores (USMLE) and how poor scores will limit the students’ abilities to pursue preferred
specialties in medicine. The literature shows that residency directors will not interview
candidates with poor scores and underrepresented students are usually the first harmed by these

48
decisions. If students are being harmed by racism and their academics are deteriorating, their
future in medicine is at stake and may be in jeopardy.
Importance and Purpose of Study
A thorough review of the literature has not shown this type of study has been conducted.
Many studies demonstrate how underrepresented students perform on MCAT exams, USMLE
exams, the stress of medical students, the admissions process and the need for increased diversity
in the workforce. This study, however, will review the academic data of students over a ten-year
period that includes the admissions data, year 1-2 grades, required clerkship scores, USMLE
scores, and their time to graduation. This data will be explained by the qualitative component,
interviews, and focus groups, to determine what experiences are faced by the medical students
and how they have affected their medical school journey.
The importance of this study will be that it can move the conversation from matriculation
of underrepresented student to the success of underrepresented students. The experiences of the
medical students can help explain the numbers found; the experiences of the medical students
can also help the administrators and faculty development programs to not only help when
struggles are apparent but develop programs to welcome all students; programs to make sure that
the subtle aggressions and concerns that are not readily apparent can be addressed.
The purpose is to examine how the campus climate, racism, microaggressions, and
negative stereotype threats influence students while they are enrolled in medical school. The
theoretical perspective of this study is Critical Race Theory, which offers insights to guide
efforts to transform aspects of our education that still hold subordinate and superior racial
positions in and out of the learning environment (Solorzano, Ceja, & Yosso, 2000). Solorzano,
Ceja, and Yosso (2000) describe that when a campus climate is positive, it includes the following

49
four elements: 1) inclusion of students, faculty, and administration of color; 2) a curriculum that
reflects experiences of people of color; 3) supportive recruiting and retention programs for
prospective students of color; and 4) a mission statement that reinforces the commitment to
diversity. This theory will lend the framework to the questions created for the survey to the
students.
The research questions this study is attempting to answer are:
1. How do underrepresented medical students experience racial microaggressions and what
influence do they have on their academics and self-efficacy in their ability to succeed
through medical school?
2. Is there a relationship between a negative campus climate of racial microaggressions and
the students’ perceptions of fit and campus experience?

50
CHAPTER THREE: METHODOLOGY
A qualitative survey will be sent to the current medical students enrolled at a western
regional medical school. The students will be asked to provide admissions data (GPA and
MCAT scores) along with other demographic data. The current enrolled class of medical
students is on average 186 per year, with an approximate total of 744 sample size. The expected
underrepresented student sample size will be approximately between 10-17% of the total number
enrolled. The stated percentage of underrepresented students is a range that is based on the given
historical knowledge of the student profiles and national statistics of medical student enrollment.
The demographic data and academic data will all be self-reported. The qualitative aspect of this
study will be from the open-ended questions asked of the students regarding their experiences,
school choice criteria, feelings of preparation, and experiences with microaggressions and
racism. The data will be analyzed using the conceptual framework of Critical Race Theory,
social capital, stereotype threats, and racial microaggressions.
Sample and Population
The total number of students invited to complete the survey was 729 and the number of
those who submitted a response was 79 (11%). The number completing the survey was expected
to be low because these students have “survey overload” and are regularly asked to complete
evaluations and surveys throughout the academic year. The breakdown of class numbers who
were invited are detailed in Tables 1 and 2; each class enrollment is approximately 186 and that
number increases and decreases as students go on leaves of absence and return.

51

Table 1: Gender and Class Level of Invited Students
Student List M1 Class M2 Class M3 Class M4 Class Totals
Male 102 (54%) 93 (50%) 98 (51%) 86 (51%) 379
Female 86 (46%) 86 (47%) 91 (48%) 83 (49%) 346
Undisclosed 0 6 (2%) 2 (2%) 1 (0%) 9
Total 188 185 191 170 734
Table 2: Race/Ethnicity of Invited Students
African American, Black, Afro-Caribbean 43 6%
Mixed Race (African American/Black) 7 1%
American Indian/Alaskan Native 2 <1%
Mixed Race American Indian/Alaskan Native 1 <1%
Pacific Islander 1 <1%
Hispanic/Latino, Spanish Origin 61 8%
Asian Chinese 107 16%
Asian Japanese 14 2%
Asian Korean 36 5%
Asian Taiwanese 33 5%
Asian Vietnamese 14 2%
Asian Filipino 9 1%
Asian Indian 54 8%
Asian Indonesian 2 <1%
Asian Pakistani 3 <1%
Other Asian 10 1%
Other 25 4%
White 247 36%
Undisclosed 74 11%

Forty one percent of the respondents are male and 59% are female. The current first year
class is 52% male and 48% female and most classes are similar in numbers of male/female
ratios. Table 3 details the race and ethnicity breakdown of the respondents. The AAMC had
identified had identified specific races and ethnicities as underrepresented in medicine: African
Americans, Mexican-American, Native American, and mainland Puerto Ricans (AAMC, 2004;
Sullivan & Mittman, 2010). The total percentage is determined by adding the numbers of

52
students who indicated they are a member of one of the designated underrepresented groups.
Approximately 15% of the respondents of this survey self-identified as one of the
underrepresented categories, which is consistent with the expectations of the results and the
national averages of students considered underrepresented.
Table 3: Race and Ethnicity of Responding Students
American Indian or Alaskan Native 0.00% 0
Asian 48.05% 37
Biracial 6.49% 5
Black or African American 2.60% 2
Caucasian or White 32.47% 25
Hispanic, Latino, or of Spanish Origin 7.79% 6
Native Hawaiian or other Pacific Islander 0.00% 0
Other 2.60% 2
Total 100% 77

Instrumentation
The theoretical framework for the interview and focus group was gleaned from Critical
Race Theory, specifically modeling this study after one conducted by Solorzano, Ceja, and
Yosso (2000), where they study the experiences of African American college students on college
campuses. The focus areas of the survey included racial discrimination experienced; their
response to any discrimination; the affect, including any academic issues; advantages of having
more students of color on campus; would they recommend the institution to any other students of
color. Odom, Roberts, Johnson, and Cooper (2007) studied the obstacles students face for
success in medical school. In this study, they conducted focus groups with students that provided
information on factors associated with success and obstacles to achieving success. The survey
questions and themes will be written using these two articles as guides.
Qualitative Survey
Creswell (2014) explains that qualitative methods studies are usually conducted at sites
where participants experience the issue under study; that the data is usually collected by

53
observing or interviewing participants; and that there are multiple sources of data rather than a
single source. The initial goal of this study was to conduct an initial survey with open-ended
questions and follow up with interviews and focus groups for more detail of the participants
experiences. What ultimately occurred was an anonymous survey that allowed students to write
about their experiences and analysis came from review of what themes emerged from the
comments provided.
Variables
Creswell (2014) defines variables as characteristics or attributes of individuals that can be
measured and usually varies between the groups of individuals being studied. Below are the
descriptions of the dependent variables that will be analyzed in this study. The independent
variable for this study will be the underrepresented status of the students in the study.
Demographic Questions. There are several variables that will be analyzed in this study.
They begin with the admissions data of all students in the study. The admissions data are self-
reported on the survey and will be used to determine the comparability of students to the
averages posted by the campus. These data include: gender, age of entry into medical school,
undergraduate science GPA, undergraduate cumulative GPA, composite MCAT score, and URM
status.
The demographic data: gender, age, and URM status are all input by the student on the
survey. The URM status was voluntary and students are allowed to enter any race/ethnicity with
which they best identify. The specific URM races and ethnicities have already been identified by
the AAMC and generally accepted by all accredited medical schools.
The remaining admissions data: undergraduate GPAs and MCAT scores, are also from
the application. In general, the students input the courses they have taken while in college along

54
with the grades earned and based on the course department (Biology, Chemistry, etc.) the science
GPA is calculated. The courses from which this GPA is calculated are those in biology,
chemistry, physics, and math. The cumulative GPA is calculated based on all undergraduate
courses taken during the college career. The MCAT score is automatically included as part of the
application as the applicant has an identifying number for all components related to the
application and testing.
Conceptual Framework of Questions
The main set of questions are mapped to concepts and theories discussed in the literature
review (Table 4-conceptual framework chart): social capital and institutional agents, critical race
theory, stereotype threats, and microaggressions. Students were asked questions using a five-
point Likert scale about expectations being met by students, faculty, and administration, their
doubts (or not) about their ability to succeed, their fit on this campus, and if they have
experienced or witnessed racism by faculty or students. In addition, they were asked to explain
some of their answers in an open-ended format. They were asked to explain why they had self-
doubt, what they attributed their ability to fit into the medical school, and why they did or did not
report any incidences of racism they may have witnessed.

55

Table 4: Theoretical Conceptual Framework
Theory Concept Questions
Social Capital
Dominance, power, priviledge,
normalizing the dominant group
and using it as a standard by which
everyone is measured.
Q10: What do you believe would have occurred if you had reported any of
these experiences with racism (overt/covert by faculty or students)?
Q11: Do you believe you have the necessary academic preparation and tools
to succeed in your medical school career?
Q15: Do you believe your social group membership has affected your
experiences in medical school? In what way?
Institutional Agents
Who to offer support,
encouragement, guidance to those
who are oppressed
Q2: What expectations did you have of the faculty, staff, and administrators
in this medical school? Have they been met? (please explain)
Q3: What expectations did you have of other students in this medical school?
Have they been met? (please explain)
Q4: If your expectations have not been met, how do you believe you have
been affected?
Q13: What is your personal support system? Do you believe it works?
Q14: Do you have institutional support to assist with your success in medical
school? (What are they or what do you need?)
Critial Race Theory
Race, racism, and power.
Experiences, stories of oppressed:
be able to view their story thorugh
their lens vs. the normalized,
dominant lens. The story of
students.
Q1: Please describe why you chose this medical school.
Q5: To what extent do you believe you fit in at this medical school?
Q6: To what do you contribute your ability to fit in or not at this medical
school?
Q7: Do you feel isolated or accepted at this medical school?
Stereotype Threats/
Microaggressions
Affect overal learning of students;
slight and subtle digs at a person
because of race/gender, etc.
Q8: Have you experienced or witnessed either overt or covert racism by
faculty, administrators, or staff? Did you say anything to anyone? Why or
why not?
Q9: Have you experienced or witnessed either overt or covert racism by other
students? Did you say anything to anyone? Why or why not?
Q12: Do you ever doubt your ability to succeed in your medical school
career?

Data Collection
The university’s Institutional Review Board has approved the study and collection of the
requested data. The students were sent the survey via Qualtrics and asked to complete the
questions as completely as they felt comfortable in answering. About five students elected not to
respond to any of the questions beyond general demographic information. One email (Appendix
B) was sent to the students with a time frame with which to complete the survey. Students were
also advised that they could stop taking this survey at any time and they could address any
concerns they had with the faculty advisor of this study.

56
Analysis of the Data

This study is a comparison between two groups: underrepresented and non-
underrepresented students (URM and non-URM). However, all racial groups listed in the survey
were analyzed and compared to each other if possible. Answers from the overarching categories
of groups (URM and non-URM) were used to answer the research questions.
Data Analysis
The demographic data will be tallied and broken into categories (age groups,
race/ethnicity groups, gender, GPA and MCAT ranges) and compared to the established national
and school averages. This data is used to determine if the student responding to the question fell
into the normed averages of admission when they responded to questions. This information is
important because of the nature of the questions asked (self-doubt about abilities and experiences
with microaggressions). All of this data will be self-reported by the students completing the
survey.
The qualitative aspects of the data will be analyzed using the conceptual framework of
critical race theory, social capital, racial microaggressions, and stereotype threats (see Table 1).
The survey questions were linked to one of the theoretical concepts and the responses to each of
the questions was reviewed while searching for themes. The themes of the responses should
relate to the concepts of the pre-established theories. The themes may overlap in their connection
to concepts and the answers may be used in multiple ways to answer the research questions. In
addition, any unexpected emergent themes will be reviewed and categorized as necessary. Once
the major themes are established, the responses will be grouped into smaller categories and
coded. Overlap of themes and concepts will be noted in the analysis.

57
CHAPTER FOUR: RESULTS
The purpose of this study was to examine the campus climate and if racial
microaggressions existed at a western region medical school and how students at this medical
school reacted to a potential negative campus climate and racial microaggressions. A survey that
contained fifteen total questions, with the majority written as open ended questions, posed
questions to existing medical students to determine their thoughts and beliefs on their
experiences. This chapter will now present the findings that emerged from the survey and
analyzed data using the conceptual framework that was constructed for the study. The results
will be divided into the two research questions answered and the themes that emerged while
answering each question.
Research Question One: Racial Microaggressions
The first research question of how students experience microaggressions and their
influence on academic performance and their self-efficacy is evident in the student responses.
Students reported that they have been a target of microaggressions by faculty, that they believed
their ability to succeed in attaining a residency of choice was in jeopardy, and that they did not
fit at the campus due to differences in background, SES, and race.
Theme #1: Incidences of Racism and Microaggressions
Students were asked if they experienced or witnessed any overt/covert racism by faculty,
administration, or students. Thirty-six percent of students (n=25) answered that they believe they
had experienced or witnessed racism and 22% (n=15) believe they had experienced it from
faculty or administrators. Of the students who responded, the racial/ethnic breakdown of how the
responded was very different:
• 20% of white students stated they had witnessed or experienced racism

58
• 46% of Asian students stated they had witnessed or experienced racism
• 50% of Hispanic/Latino students stated they had witnessed or experienced racism
• 100% each of Black/African American and Biracial students state they had witnessed or
experienced racism
Of the students who did not witness/experience racism, they felt they that a “simple
misunderstanding is all too often blown out of proportion into some secret sign of ‘systemic’
racism”. (Student 16, Male [identified as other], MS2, Student Survey, 2017). One student
reported that “as a woman of color, I have not witnessed instances of racism or microaggressions
towards students or faculty. We have a very accepting culture.” (Student 57, Asian female, MS4,
Survey, 2017).
The follow up question to these are whether or not students had reported any of these
instances. Many the responses indicated that students chose not to report any instances. The
student comments express a fear of repercussions or state that the instances were so small they
did not seem worth reporting or important enough to report:
“…my [instructor] said several very racist remarks. I did not report
them to anyone, because I did not know who to report them to, and I
was afraid that it was going to get back to my [instructor] and that she
would know it was me who reported her.” (Student 47; Caucasian
female, MS2, Survey, 2017).
“I wrote about them in evaluations, but I didn’t feel comfortable
lodging an official complaint.” (Student 28, Asian female, MS2,
Survey, 2017).

59
“I didn’t report these instances. The ones I experienced first-hand were
relatively covert, and though I recognized the racist connotations, I did
not feel personally offended enough to report the person.” (Student 22,
Asian female, MS2, Survey, 2017).
“I did not personally report any of these instances to anyone.
Sometimes, I felt that reporting the offense would be overreacting to a
small gesture/phrase.” (Student 19, Asian female, MS2, Survey, 2017)
What is most interesting, was the reaction to what is considered microaggressions. Based
on student comments, a majority believed what they saw “wasn’t worth reporting” or that they
did not witness anything “overt”. Their comments demonstrate that in order for a comment to be
racist, it must be obvious, directed toward someone specifically, or that they weren’t “severe
enough to require that kind of attention”. Interestingly enough, one student specifically stated she
had witnessed or experienced racism, yet did not report it because they are microaggressions.
This survey question demonstrates that students know what microaggressions are, that all racism
is not necessarily overt and egregious, yet, does not rise to the level of needing to be reported
because it is so minor.
Theme #2: Self-Efficacy and Stereotype Threats
Common themes that emerged about doubts were because of the overwhelming amount
of material they are expected to study and learn and adjusting to the new study pace and plan
they must adapt in order to succeed. In conjunction with the initial adjustment of a new study
plan is the adjustment of admitting and understanding that they now do not know everything and
they are in class with people who are at least as smart as they are and in many cases, smarter. In
addition, they have other stressors of trying to find balance, inter-class competition (real or

60
perceived), perceptions of how others are feeling/managing compared to self, and standardized
test requirements that will lead to a preferred residency match. However, even though the
admissions process is rigorous and the average GPA is one of a high performing student,
respondents indicated:
“No one believes in people like me. All my life I’ve had to fight. The
career counselor at (medical school) told me that I needed a plan
because my grades are not adequate as I prepared my ERAS
application. The question should be how do I continue to believe in
myself despite everyone doubting me.” (Student 27, Hispanic/Latino
female, MS 4, Survey 2017).
“Because I am the first in my family to ever graduate high school and
ever go to college and medical school).” (Student 50, Hispanic/Latino,
female, MS 1, Survey 2017).
“Feeling incompetent/overwhelmed by academic material.” (Student
70, Asian female, MS 4, Survey 2017).
Another student just answered briefly by saying “self-doubt, being blamed or harassed”.
History of being doubted has made it difficult for one current medical student. “The main doubts
that I have had in the past have been caused by other students who have made me feel like I was
not smart enough, or as smart as them.”
More than a few students reported that they felt anxiety, insomnia, ADHD, and
depression which increased their self-doubt. Their comments also qualify that these feelings
come from hearing rumors from senior students about how difficult it is and the methods in
which the assessments/grading occurs in medical school. Students feel they are not succeeding

61
because they are unsure of how to determine how well they are learning until they have a final,
high-stakes exam. Finally, anxiety and self-doubt are present because medical students must
learn to manage their own self-expectations of performance.
Imposer syndrome and comparing oneself to peers is another issue raised by students’
responses. “Overwhelming nature of the stress of school and the expectation to master the
material in such a short time along with the pressure of classmates and constantly judging myself
against them”. Other comments are: “how smart everyone is”, “feelings of inadequacy”, “my
perception of relative incompetence compared to other students”, and “perceptions that everyone
is doing more than I and doing those activities better than I am”.
The second part of the first research question focused on students’ self-efficacy and the
answers were provided by the survey question regarding students’ doubt about success and the
causes of doubts. The responses varied on this, with the majority of respondents (n=40, 58%)
answering definitely or probably yes to the question of whether or not they had doubts about
their ability to succeed in medical school. Of this group, the racial and ethnic breakdown of
respondents is:
• 63% of Asian students definitely or probably felt doubts about success
• 18% of White students definitely or probably felt doubts about success
• 8% of Hispanic/Latino students definitely or probably felt doubts about success
• 6% of Biracial students definitely or probably felt doubts about success
• 4% of Black/African American students definitely or probably felt doubts about success
When viewing this data without context, it seems that more Asian and white students feel
doubt more than students considered underrepresented. However, when this data is compared
with the enrollment data, underrepresented students overwhelmingly feel doubt more than their

62
peers. For the four classes surveyed, 53% is Asian, 36% is white, 8% is Hispanic/Latino, 6% is
Black/African American, and 1% is Biracial. This data shows that 100% of the Hispanic/Latino
and 67% of Black/African American respondents doubted their ability to succeed in medical
school, even though they are within the top 8% of total applicants to this medical school.
Research Question One Summary
The research question of how do underrepresented medical students experience racial
microaggressions and what influence do they have on their academics and self-efficacy in their
ability to succeed through medical school was partially answered based on this survey. When
reviewing the data, students who are considered underrepresented experience and recognize
racism and microaggressions more than their peers. What is evident through this survey, is that
the majority of students who experienced or witnessed racism did not feel confident enough in
the system to report these instances, did not feel anything would change if they reported, and did
not recognize that they should report microaggressions that seem frequently occur.
As with experiencing and witnessing racism, underrepresented students also had a lower
self-efficacy about their ability to succeed in medical school when compared to non-
underrepresented peers. As noted above, 100% of Hispanic/Latino and Black/African American
students doubted their ability to succeed. The experiences of racism only serve to confirm some
of those doubts.
The portion of the research question which is not clearly answered is whether or not
students’ academics were harmed in any way by these experiences. The survey did not elicit
enough information in order to provide any data on this question. When the survey was drafted
and proposed, the idea of interviews and focus groups was still in place and this data was
planned to be gathered from questions following the survey.

63
Research Question Two: Campus Climate and School Fit
The second research question is about the relationship between a negative campus
climate and the students’ perceptions of fit and experiences. This question is answered by
questions relating to support and institutional agents, reasons of attendance at this school, social
groups, and their overall belief of how they fit at this medical school.
Theme #1: Attendance and Institutional Agents

Students were asked about why they chose this medical school and about their
expectations of faculty, staff, and students. They were looking for culture, a certain type of
patient, and expected that there would be some support along their journey into becoming a
physician. And, while many stated it was because of the clinical population they would work
with, others also chose this school because they saw ‘themselves’ in members of the
administration. One student reported “because of the amount of black and Latino deans, I
expected a diverse institution that would support me as a woman of color physician.”.
“I chose this school because everyone I met during the interview day
was a woman of color. [Dean] made it very clear that the population
…serves is marginalized. I ended my day with a 2-hour conversation
with [Dean] at the office of Diversity and Inclusion. I had an
expectation that everyone else at the school would share similar
convictions about the importance of social justice in medicine.”
(Student 32, Asian female, MS 2, Survey 2017).
“I wanted to train and serve [this population and city] that closely
aligned with my culture.” (Student 38, Hispanic/Latino Male, Survey
2017).

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“I chose [this school] based on the clinical opportunities I would have.
Additionally, the student body seemed very tight knit and it was
something I could see myself being a part of.” (Student 80,
Black/African American Male, Survey, 2017).
Ultimately, students chose a place where they felt they would fit in, be part of a
community that holds the same values, and be inclusive to all types of cultures and groups. When
they responded to whether or not they believed their expectations of the school were met, only
16% of the total respondents indicated that their expectations were probably not met. One
student was very firm in her answer to this question in that she definitely did not believe any of
her expectations were met. She also indicated that she has experienced racism, that she is not one
who is considered a strong student, and that she was told she would not have a very strong
residency application.
The bridge between fit and institutional agents is strong as well. Students believe they fit
so well because they are welcomed by the students, faculty, and staff. They believe the culture is
welcoming and if you are willing to be engaged and interested in something, you will find your
place. One student attributed her ability to fit in and be successful to the fact that she found
friends, teachers, and “other allies” who she trusts and who trust her. In many respects, friends,
teachers, and allies are the very definition of institutional agents and without those, experiences,
fit, and comfort level in any situation is diminished.
Theme #2: Social Group Influencing Experiences and School Fit
Eighty-eight percent of students answered or probably yes to the question of belief that
their social group membership effected their medical school experiences. They believed they fit
in with a laid-back culture of this school, they had common interests in medicine and science, or

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that they are adaptable in many situations and they find new friends to have a positive experience
with.
Students were asked if they felt they fit into this medical school and 77% feel extremely
or moderately comfortable at the school. Students felt that if they were of a higher SES it was
easier to fit in and had a more positive experience. A male, biracial student commented “being
upper-class and having a science background” positively affected his experience. Unfortunately,
this comment is in direct opposition to another student who does not feel comfortable at the
school because her “age, ethnicity, background, financial status” are very different than her
peers. One student felt that the diversity of the school was a benefit to their ability to be
comfortable at the school.
The comments by those who do not feel as if they fit centered around their own
introversion, one mentioned he/she had a history of depression, or that they have found a group
of friends in which they are comfortable with. In addition, many comments focused on drinking
and partying, which did not confirm to their belief of appropriate behaviors for medical students
nor did it make it easier for students to find friends with common attitudes. A female student
commented that she felt she did not find the right friends in her first year. She continues “the
people I made friends with last year have seemed a lot more immature than I thought they would
be-in their analysis of situations and social thinking than I would expect from a fellow medical
student.” (Student 45, Caucasian Female, MS 2, Survey 2017). Students also mentioned that
because of their background, they were unable to fit into the school.
“I’m Filipino and from a more underserved background, and some of my
classmates can’t relate to me well. (they don’t know about my culture or
how I grew up). I’ve had really close friends in high school and part of

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college, and I noticed that they all tend to come from less affluent
backgrounds and are a little less judgmental than the students here…I
am rather slow at processing information, and it sometimes makes
people feel awkward/uncomfortable.” (Student 12, Asian Female, MS 2,
Survey 2017).
Research Question Two Summary
The second research question of this study questions how the students felt about their
campus experience in relation to how they fit into the school. It is believed that interviews would
have offered a more robust conversation about this question and allowed for more detail in
responses, students who responded to this survey were still very forthcoming in their responses.
They believe that being able to have friends, a social group who supports you, teachers, allies,
and staff who support and help are all avenues of success in a rigorous medical school program.
Unfortunately, many students also believe (on both ends of the spectrum) that one’s socio-
economic status influences how they fit at this campus as well. Students indicated that they
believed they fit better because they considered themselves “upper-class” and in contrast, they
stated they did not fit well because of their lower financial situations.
Results Summary
The most concerning finding of this study is the fact that students do not seem to
understand the pervasive problem with microaggressions and why they should be reported to
administration and faculty. Microaggressions seem innocuous, however, with reoccurance, they
make students question themselves: ‘did I hear that correctly?’, ‘am I actually in the right
place?’, ‘can I do this?’. They make students question what is happening, therefore, their self-

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efficacy begins to erode. There is a connection between stereotype threats, self-efficacy, and
microaagressions in how the students tend to react when they feel uncomfortable or threatened.
In addition, students’ question their fit on campus when the above is occurring. If they
do not believe they belong, this study has shown that they question their ability, they believe they
are not supposed to be there [imposter syndrome], and unfortunately, an end result could be poor
performance on high-stakes assessments and metrics. These negative feelings can be overcome,
as demonstrated by many comments, by having institutional agents. When a student sees
someone with whom they relate, with whom they trust, they know they are in the right place and
can see how they belong on this campus at this time. Taken together, students need institutional
agents so they feel more comfortable reporting microaggressions that are happening regularly.

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CHAPTER FIVE: DISCUSSION OF FINDINGS
The purpose of this study was to examine how the campus racial climate,
microaggressions, and negative stereotype threats affect the performance of students while in
medical school. The goal was to determine if there was a difference in the experiences between
students considered underrepresented and those of the majority groups. The theoretical
perspective of this study is Critical Race Theory and social capital and the survey questions were
developed with those conceptual frameworks. The questions the survey attempted to answer
were:
1. How do underrepresented medical students experience racial microaggressions and what
influence do they have on their academics and self-efficacy in their ability to succeed
through medical school?
2. Is there a relationship between a negative campus climate of racial microaggressions and
the students’ perceptions of fit and campus experience?
The survey was comprised of 15 questions about demographics, medical school
admissions data, as well as open ended questions asking the respondents to explain their view of
fit at the medical school, experiences with racism by administrators, faculty, and students, and if
they reported any instances.
Findings
The findings of this research were divided into four themes: incidences of racism and
microaggressions, social group and its influence on school experiences and fit, institutional
agents and their support on medical students’ success, and critical race theory and stereotype
threats. Each of these themes has been created to answer the two established research questions
and were drawn from the literature review.

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Critical Race Theory and Stereotype Threats
Critical race theory suggests that color-blind expressions and statements of equality only
absolve obvious forms of racism (Delgado & Stefancic, 2012). The theory is important as it
allows the oppressed to help those in an educational environment understand their experiences
through their lens, rather than the lens of the dominant, normalized culture. Allowing our
medical students to tell their story and discuss their experience with those in power will allow the
school gain an understanding of what they can do to support students and change the culture.
The theory behind stereotype threats assumes that students who are successful in school
have established an identity with the school and the pressures and negative stereotypes threaten
the internal belief system of students in color to the point where their academics suffer and
students become disconnected from the school (Steele, 1997). Like the idea of a positive campus
climate, students are more successful when they believe they belong and the feelings they have
when they are achieving their own expectations. In medical school, the hierarchical structure is
very well established. Students who face barriers such as socioeconomic barriers, segregation,
and other barriers that include inadequate role models and academic preparation, make it more
difficult to form a positive identity with the school; students with these barriers often feel as if
they do not belong and that they are imposters playing a role (Schmader, 2010; Steele, 1997).
The findings of this study were not surprising in that they confirmed that students do feel
as if they are the ‘token’ member of their race and that they do not always fit into the medical
school. Students felt they struggled with the amount of material they were expected to know, that
they were not as smart or prepared as their peers and were generally falling victim to established
stereotypes that they were not good enough or ready for medical school. Students are questioning

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how they can believe in themselves when the staff and faculty do not believe in their ability to
succeed.
As discussed very early in this study, medical school is the great equalizer for smart
students. In general, those who are accepted are the smartest, brightest, and best test-takers.
Nationally, the average GPA and MCAT scores are in the top 10% of academics of students in
college. Acceptance into medical school for a student who has self-doubts and is made to feel as
if he/she does not belong begins to erode confidence. The acceptance can easily be set aside as
an affirmative action result or accepting a ‘token’ member of a group; the doubts of success will
continue to linger. “Anxiety, not being able to fit in, academic struggles” are listed as reasons for
self-doubts by one student. This student continues to state that feeling incompetent while
working on the wards has given him/her doubt of being a successful physician. One student
reported “Medical school is, by definition, challenging for even the brightest and hardest
working students. Although I did quite well in general, there were definitely some systems and
assessments where I felt frustrated and down about underperforming relative to other
students…”.
The limitations section will go further into detail, however, a focus group or interview
with individual students would allow one to probe these concerns further. It would give a
researcher an opportunity to determine whether the respondents who are experiencing self-doubt
and concern are actually under-represented, or another student who also does not feel as if he or
she belongs in medical school.
Incidences of Racism and Microaggressions
The findings of racism and microaggressions were more surprising, more in that the
students seemed to take what, by definition is, microaggressions, in stride. They chose not to

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report these incidences because they believed them to not be “worth the trouble”. Solorzano,
Ceja, and Yosso (2000) and Sue, Capodilupo, Torino, Bucceri, Holder, Nadal, and Esquilin
(2007) all define racial microaggressions as subtle, common insults toward people of color. Sue,
Capodilupo, et al. (2007) continue to speculate racial microaggressions are powerful because
they are often small acts that are easily explained away and the recipient is left wondering if it
actually happened. These small acts are what students have decided are not worthy of reporting.
These small acts are what can erode a positive campus climate and students’ confidence in their
abilities to succeed in medical school.
Beagan (2003) studied racism in medical students who are enrolled in medical school and
similarly defined microaggressions as normalized transgressions that are not necessarily intended
to be insulting. Beagan’s study also found that incidences of racism in medical school did not
seem to be an issue because on the surface, the school seemed to be diverse with a multicultural
community. Students who responded in this survey by and large reported that one of the reasons
they attended this medical school was the diversity of the student body and the diversity of the
patient population. Some students went so far as to say they have not witnessed any instances of
racism toward student or faculty because of the accepting culture. Students commented that they
didn’t report instances because they were “relatively covert” and the student did not feel
“personally offended enough to report them”.
The final surprising finding is that fear that students face when faced with the need to
report these instances to senior faculty or administration. They were concerned with
repercussions of reporting and concerned that nothing would be done with their complaints. The
power differential in medical is real and the hierarchy of the faculty who evaluate students, who
interview them for residency positions, who write the letters for those residency positions is a

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real fear for medical students. They are hesitant to report any aggressions toward them for fear of
retaliation. Beagan (2003) addresses this power differential by concurring that students will not
report slights against them even it erodes their confidence and ability to succeed in the long run.
Social Group and School Experiences and Fit
Steele (1997) discusses that successes in academic environments is tied to the students
developing positive feelings toward the campus and feeling as if they belong in that
environment. Stereotype threats and racial microaggressions are what prevents students from
developing those feelings. As Appel and Kronberger (2012) demonstrated, overall learning is
negatively affected by a negative environment. Power and privilege also have a part in the
students’ comfort and fit within the educational environment. Johnson (2006) suggest that power
and privilege exist because of the social systems and one’s participation within them. The
normed standards are set by the privileged group and society takes the path of least resistance in
following those standards. Students of color, who may already be experiencing ‘imposter
syndrome’ are left out of that society because they do not fit the established norms or standards.
The findings of this study were quite disparate and diverse. Many students reported that
diversity in the school was apparent and that the school enrolled a large number of minority
students; this enrollment leading to positive feelings of comfort and fit. Other students felt that
many of the students had a high socio-economic status and were of a higher “class” and that they
did not feel part of a social group or fit into the school as well. The findings were on both ends of
the spectrum so it is difficult to draw any specific conclusions as to what the students are saying
beyond the fact that some felt segregated from their peers because of a lack of similar interests
and others felt they were able to fit in well because they were more “adaptable” and “flexible”
and that they can move between different groups very well.

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Some students commented that their ability to be flexible and the fact that many had the
same overall interests, medicine, the fit was automatic. On the surface, this would be correct,
unless of course, the student in question is one of an underrepresented or underprivileged status
and they already have doubts about their ability to succeed and attainment.
Institutional Agents
Social capital theory posits that underrepresented and oppressed students need to have
social capital and networks in order to successfully navigate the structure of the educational
system (Stanton-Salazar, 1997). Many middle and upper-middle class children have this social
capital through institutional agents; parents, teachers, friends of parents, and peers are able to
offer advice and information on the intricacies of the educational system that underrepresented
students may not have access to. In fact, educators who see students with this type of capital
automatically assume they have talent and extend higher expectation along with encouragement
and support (Stanton-Salazar, 1997). Resources to these students is extended and those without
this type of capital are left to struggle.
The responses to the survey question of why students chose this medical school varied
and should, in theory, negate the previous responses of racism and microaggression acts against
the students. Students chose it because they believed it to be a culturally inclusive, laid-back
institution, that would allow them to study to become a physician by working with an
underserved population in an urban hospital. Many of the students reports confirm this belief and
hope while others had very different experiences. Across the board, however, the students who
felt they were comfortable in the institution had found support and agents to help them succeed.
Ultimately, as Stanton-Salazar (1997) notes, the development of students who are
underrepresented and disadvantaged depends on their ability to move across different worlds and

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having institutional agents who are able to bridge that path and give students the opportunity to
see what they can do is invaluable. Ovink and Veazey (2011) conclude that students can
overcome inherent institutional barriers by targeted interventions and support. Institutional
agents are the first step on that pathway.
Limitations to Sample and Instrumentation
The first limitation to this study was the sample size. When conducting a survey, the
return rate is usually lower, even when incentives are offered. The flip side of having easier
access (convenience) of this sample is countered by the sample size that was expected when the
survey was conducted. Second, much of the admissions data was self-reported as opposed to
collected from official, university documents. The preference of collecting academic information
from official documents is that the data is verified by official transcripts and exam scores. When
students are asked to self-report this data, they tend to be generous and inflated as they may not
want to appear to have not been prepared.
The third limitation relates to the selected measurement of data collection, survey. While
the questions were designed to be open-ended and allow for space to go into detail and explain,
there is no opportunity to ask for additional information or clarification based on responses. The
nature of the questions is such that once the respondent writes a response, it is natural to ask for
further clarification, more information, and/or a follow up question. The survey keeps a distance
from the respondents and prevents a possible conflict of interest, however, the survey also is a
list of static questions so they must be written to allow for additional information if warranted.
Another sampling limitation will be the disparity of the numbers of underrepresented
students when compared to the non-underrepresented students. It is expected, given the historical
data provided by the school, that the underrepresented numbers will be between 10-17% of the

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class. As these numbers are generally consistent with the overall numbers of enrolled
underrepresented students in all U.S. medical schools, it is unavoidable.
The final limitation to the sampling was the convenience sampling of the students who
participate in the survey. Students were allowed to self-select to participate and there is no way
to guarantee that any underrepresented students respond and that a complete representation of the
class will be reached. In addition, medical students are inundated with surveys/assessments that
are mandatory and one additional one, even one that is short, is usually met as unwelcome.
Delimitations
The primary delimitation is access to historical admissions and academic data. The
original goal was to collect this data (as opposed to having it self-reported and from current
students) and compare the admissions data and the completed academics of alumni. The goal
was to have data provided from university information and compare it to the established
information of current students. The admissions criteria are similar and the requirements of
graduation are similar so a comparison would have been straight forward. From that data,
questions could have been asked of current students to gain an understanding of their experiences
while enrolled and if those experiences affected their academics. The school had concerns that
the historical admissions data was not consistent with current practices and denied access. In
addition, it was established that a potential conflict of interest was possible, and they asked that
interviews and focus groups not be conducted. The remaining option was to create a survey of
what would have been asked in focus groups and interviews and ask the respondents to report the
academic data that would have been provided in official documents. This delimitation
unfortunately limited the opportunity to collect robust information and connect the dots to
problems with academics based on concerns with the climate and environment of the school.

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Finally, the original goal of this study was to gather demographic and basic data via a
survey and follow up with additional questions in an interview or focus group format. The school
leadership team requested this portion of the data collection not happen due to potential conflicts
of interest and possible power influences due to my role at the school. To overcome this issue,
the survey was recreated to include more open-ended questions to gather as much qualitative
data as possible while still not overburdening the students. The inability to conduct the focus
groups and interviews greatly limited the option of follow up and detail that would have
enhanced the data and richness of the study.
Implications for Practice
According to Solorzano, Ceja, and Yosso (2000), the four components that must be
present for the racial campus climate to be considered positive are: a) inclusion of students,
faculty, and staff of color; b) a curriculum that reflects the experiences and historical context of
people of color; c) programs that support recruitment, retention, and completion of students of
color; and d) the mission and practice that reinforces the institution’s commitment to diversity.
The implications detailed below support these four components.
Inclusion
A positive campus climate must be inclusive of faculty and administration of color. The
students must be able to see themselves in the representation of the leadership and see how they
belong on this particular campus. Because the campus is a medical campus, the hierarchy and
power structure is already significantly displaced toward the physicians, who are also faculty.
When the student is a person of color, the power structure is more pronounced. Many physicians
are white males and the socio-economic status is pronounced. Even with these issues stated,
inclusion of students, faculty, staff, and administration of color is apparent. A significant number

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of the senior leadership team at this medical school is not only female, but females of color. The
dean is a person of color and the leadership not only allows for students to raise their social
justice concerns, they encourage it and support and stand with the students.
However, since students are still reporting that they question their fit in medical school,
that they feel as if the faculty question their presence because of their race, there is still more
work to be done. One thing that was done is the school dedicated a Student Diversity Lounge for
students to gather. Solorzano, Ceja, and Yosso (2000) call this type of space a “counter-space”,
which was developed with the intent of serving students of color who needed a safe place to be.
Curriculum
The curriculum is a critical component of a positive campus climate. It should reflect the
experiences for people of color and the medical school curriculum is rich with opportunities to
be enhanced. The Liaison Committee on Medical Education (LCME) and the Association of
American Medical Colleges has set forth standards for all U.S. medical schools to graduate
physicians who are culturally competent, understand healthcare access, disparities, and are able
to work with a diverse population (AAMC, Mission and Vision, 2004; LCME, 2014). The
medical school curriculum is reviewed during accreditation to ensure these elements are present.
This particular medical school has both formal and informal components discussing
social justice concerns, access, disparities, and the needs of a diverse population. Students who
are part of a Social Justice Interest Group presented how they believe the faculty are able to
informally include aspects of these components into their lectures without much revision.
There is a longitudinal course that has learning modules that discuss a variety of social
justice issues. These topics include: gang cultures, LGBTQ patients and families, access to care
and disparities, and differences in religion. The students are exposed to these issues throughout

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the year and are able to talk with the different populations about issues they face with the health
care system. In addition, there are certain activities within the required clerkships that
incorporate access and care to underserved populations.
However, for the curriculum to be truly inclusive, a formal process should be proposed.
Each lecturer and course director should determine how they can incorporate disparities and
diverse patients into their lectures and presentations. These faculty should ensure they consider
access of care and what that means to the physicians providing care. Objectives and learning
goals should be more reflective of the need to have physicians who are not only culturally
competent, but who are culturally humble and aware. The administration has made some strides,
however, there is still more work to be done for this to be truly inclusive.
Student Programs
The third element of a positive campus climate for under-represented students is having
programs to support recruitment, retention, and graduation (Solorzano, Ceja, & Yosso, 2000). In
the medical school environment, programs to support students of color should begin with
preparation and post-baccalaureate programs. These programs are designed to support
disadvantaged and underrepresented students and help them prepare for entrance to medical
school. Recruitment/admissions practices should be considered next when working with
underrepresented and students of color. Finally, programs for students on campus and those
designed to support them through graduation and preparing them for standardized exams and
residency are necessary.
Pipeline/Post-Baccalaureate Programs. Many medical schools offer post-baccalaureate
programs. They are considered either career-changer programs for students who earned a degree
in something other than science and students need science/math prerequisites. The other type of

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program is one designed for students to improve their academics after Bachelor’s Degree
completion. The University of California medical schools have created a consortium of second
chance post-baccalaureate programs, for which these programs are specifically designed to
increase matriculation to disadvantaged and minority students (Grumbach and Chen, 2006). This
pipeline set of programs works to not only provide disadvantaged students with the necessary
academics to attain admissions into medical school, but they also offer guidance and counseling
for students to learn many skills to achieve success. This consortium of programs has better than
a 85% success rate of enrolling disadvantaged and minority students into medical school.
This medical school should consider this type of program for disadvantaged students. The
students who are able to enroll will be given counseling and application guidance; they will have
the opportunity to shadow and conduct research with the existing faculty; they will also have
access to the current Admissions team and learn what they need to do in order to attain
admissions. Another option is working with the undergraduate campus on creating a bridge
program for undergraduate disadvantage from a positive model instead of a deficit model. This
type of program would allow students to enroll early in their academic year to receive
specialized support throughout their college career. The reason this is a better option is that
students are supported from college entry as opposed to remediated because they had life issues
that caused some academic set-backs. The University of California, Davis has a Biology
Undergraduate Scholars Program (BUSP) that is designed to attract and retain underrepresented
and disadvantaged students. Underrepresented students can gain the necessary social and cultural
capital to not only attain a baccalaureate degree, but also begin working toward the next step of
their education (Ovink & Veazey, 2011).

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Admissions Practices. As mentioned in the literature review, the AAMC and the LCME
have set forth standards by which schools practice admissions. The application process is
standardized; however, the schools are able to have individualized policies. The AAMC has a
Holistic Admissions Process where they have encouraged schools to review not only the
numbers on the students’ application, but also the non-tangible attributes offered on the
application. These attributes are life experiences, background, race/ethnicity to the extent that it
explains some of their life experiences (AAMC, 2004; Monroe et al., 2013).
While all U.S. public, state medical schools are also bound by state law in their use of
race/ethnicity in their admissions policies, private schools may have more latitude. They can
create programs to specifically recruit minority students, and certainly offer scholarship
incentives to encourage enrollment into those programs. At a minimum, these private programs
can ensure that the weighting of different admissions criteria is done on an individual basis and
not standardized across all applicants. Applicants to medical school should be reviewed on their
own merits and not compared side-by-side to other applicants. If the school were able to create a
post-baccalaureate or pipeline program, they could then receive special admissions
consideration.
Retention/Enrollment Programs. Underrepresented and underserved students need a
safe place to go on campus that allows them to feel as if they belong. According to the literature
and the results of this survey, students of color already feel as if they are imposters, they fall
victim to stereotype threats, and do not always feel as if they fit on a campus whose students are
from a higher SES, who are not first-generation students, etc. Retention programs for enrolled
students is imperative because the inherent stressors of medical school are enhanced when one
adds in the stressors of being underrepresented in a place they do not feel as if they belong to.

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The Office of Diversity and Inclusion is a newly created office dedicated to recruiting,
retaining, and increasing the numbers of minority students enrolled at this medical school. They
provide counseling to these students and have a goal of preparing all students for the diverse
populations they will encounter during their education and future training. Some of the
sponsored activities of this office are bringing in speakers to discuss bias, privilege, and cultural
humility and competency. These topics are not only discussed broadly, they are discussed as it
related to these particular medical students and their journey embarking into the medical
profession.
In addition to having guest speakers, ongoing programs could be created to support a
diverse student body and create an inclusive and welcoming environment. These programs
should include: Women in Medicine, Women of Color in Medicine, LGBTQ Groups, Men of
Color in Medicine. Student interest groups and organizations already exist and the above topics
may be in existence, but if they are not, they should be created and fostered.
Finally, the stigma of needing academic support must be eliminated. The very nature of
medical school admissions means that medical school students are typically the students who
graduated at the top of their undergraduate classes and their academics are stellar. In addition,
this environment is highly competitive and students inherently compare themselves to their
peers. If a student of color already feels as if he/she is an imposter or that he/she is not as smart
as the others, this comparison will create a situation where they do not feel as they belong and
they will fall into a stereotype that maybe they should not be at this school. The school has to
create something that removes the stigma of asking for academic help. Students should not be
expected to navigate the difficulties of medical school alone and they should feel that if they seek

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help from the Academic Support Center, they are not failures. Changing the culture is a long-
term project that must be considered.
Future Research
While the small sample size of this scholarly study is defined as a limitation, it is still
believed that a need for a positive racial campus climate at medical schools is needed. Students
are still feeling they are not included, feel imposter syndrome with their attendance, believe they
are the lone voice of their respective racial/ethnic group and these experiences can affect how the
students integrate and fit into the school. Future research needs to include longitudinal studies
that follows medical students through their journey and that includes programs already in place
and if they are effective in changing the perspective of the enrolled students. The research should
surveys, focus groups, and specific interviews with students of color, with students from the
dominant groups, both genders and should be expanded to include students who’s sexual
orientation and gender identity are considered outside the established dominant groups. The
focus of this research was toward racial microaggressions, however, other groups are still facing
many of the same issues of disrespect, oppression, and their experiences must be catalogued.
Conclusion
For all aspiring physicians, the path into medical school is rife with many hours of
studying, starting off believing that the same study habits developed in undergraduate school will
work in medical school, for some, the plummet into reality when students realize that their
previous habits will not suffice, and then the transition into clinical work and onto becoming a
physician. However, for students of color and for those who are already underrepresented as
post-graduates in medicine and in the medical field, this path also contains doubts delivered by
counselors, faculty, other students, and they are compounded by your own doubts and fears of

83
the ability to succeed on this journey. This study has been a question of differences; what are the
different experiences for students of color and underrepresented students? What is the campus
climate like for these students? Do these differences affect their academics? Do they determine
the success of underrepresented students?
The results of this study are mixed. There are some conclusions and some questions that
need more research to be fully answered. One conclusion is that there are still instances of racism
and microaggressions against students in medical school. The established hierarchy in medical
school make it difficult for students to want to report the incidents because of worries of
retaliation. The unanswered questions are whether or not these instances have fully affected the
academics of underrepresented students. The established programs in medical school are
designed to support students who are struggling, so very the attrition rate of medical students is
very low; however, further research can help define what programs would help alleviate
academic issues induced by self-doubt and struggle. Focus groups and interviews will allow
students to continue to tell their stories and provide insight as to what they believe will create a
climate and environment that will allow them to belong and fit on a campus, similar to those who
already believe they are part of the campus. Change will be a long time coming because there are
faculty who have been teaching for many years and their beliefs are ingrained. However, we as
institutional agents have to gain the understanding of the students’ experiences and begin the
process of opening access to school for all students.

84
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92
https://www.washingtonpost.com/news/grade-point/wp/2015/11/09/missouris-student-
government-calls-for-university-presidents-removal/

93
APPENDIX A: SURVEY
You are invited to participate in a research study conducted by Christine Crispen, candidate for
the Doctorate of Education Degree, and Dr. Patricia Tobey, faculty advisor, at the
University of Southern California, because you are a current medical student. Your
participation is voluntary. You should read the information below, and ask questions
about anything you do not understand, before deciding whether to participate. Please take
as much time as you need to read the consent form. You may also decide to discuss
participation with your family or friends.

STUDY PROCEDURES
If you volunteer to participate in this study, you will be asked to complete an online, anonymous
survey. Themes to be discussed are your experiences at this medical school, how you
believe they have affected your academic performance, and if you have experienced
racism/microaggression while enrolled at this medical school.

POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated risks associated with this study, although, you may feel uncomfortable
with the topic and discussing this topic with me.

PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may withdraw your consent at any time
and discontinue participation without penalty. You are not waiving any legal claims,
rights or remedies because of your participation in this research study.

INVESTIGATOR’S CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact Christine
Crispen (Principal Investigator) at ccrispen@usc.edu or Dr. Patricia Tobey (Faculty
Advisor) at tobey@usc.edu.

RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to
someone independent of the research team, please contact the University Park
Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los Angeles, CA
900890702, (213) 8215272 or upirb@usc.edu

By selecting Agree below, you indicate you understand the risks as outline above and are
voluntarily participating in this study.

94

The gender I identify with:
Male
Female
Decline to state

Age at matriculation
2325
2628
Over 28

How do you selfidentify?
Asian
Biracial
Black or African American
Caucasian or White
Hispanic, Latino, or of Spanish Origin
Native Hawaiian or other Pacific Islander
Other

In what year of medical school are you?
1
st
Year
2nd Year
3rd year
4th Year

What was your undergraduate GPA upon admission into medical school?

What was your final MCAT score upon admission into medical school?

Have you passed all required systems/courses to date? If not, how many have you remediated?

Please explain why you chose this medical school? What expectations did you have?

Have your expectations of the faculty and administrators been met?
Probably yes
Might or might not
Probably not
Definitely not

Have your expectations of the students been met?
Probably yes
Might or might not
Probably not
Definitely not

95
To what extent do you believe you fit in at this medical school?
Moderately comfortable
Slightly comfortable
Neither comfortable nor uncomfortable
Slightly uncomfortable
Moderately uncomfortable Extremely uncomfortable

To what do you attribute your ability to fit in or not at this medical school?

Have you experienced or witnessed either overt or covert racism by other students?
Probably yes
Might or might not
Probably not
Definitely not

Have you ever experienced or witnessed overt or covert racism by the faculty or other
administrators?

Probably yes
Might or might not
Probably not
Definitely not

Did you report any of these instances to anyone? Why or why not?

Do you ever doubt your ability to succeed in medical school?
Probably yes
Might or might not
Probably not
Definitely not

If you have doubts, what has caused them?
Do you believe your social group membership has affected your experiences in medical school?
Probably yes
Might or might not
Probably not
Definitely not

96
APPENDIX B: EMAIL SOLICITATION OF STUDENTS FOR SURVEY

Dear Keck School of Medicine Students,

I am a third year doctoral student completing my dissertation on the influence of campus climate
on academics in the Ed.D. program at the Rossier School of Education at USC. The final hurdle
in completing my dissertation is conducting this survey and analyzing the results and I am asking
for your assistance.

If you are able and willing, please complete this survey (Campus Climate Dissertation Survey)
between now and October 31, 2016. It should take you approximately 15-20 minutes to complete
and I am offering up to 10 randomly drawn Amazon gift cards as well as one grand prize
drawing for those who complete the survey.

If you are interested in being part of the gift card drawing, please go to my Google Docs
Spreadsheet (https://docs.google.com/a/usc.edu/spreadsheets/d/1WTPPDpu8BnBPp-
rA1bmCCmjjJe7Jtl2DEFFhQFXWAvg/edit?usp=sharing) and enter your email address only.
The winner will receive their prize electronically.
Please note, this survey is completely voluntary and you may end it at any time. Your responses
are going to be analyzed in aggregate and no identifying information is attached to the responses.
If you have concerns regarding this survey, the faculty chair for my committee is Dr. Patricia
Tobey and her email is tobey@usc.edu. You are welcome to contact her with your concerns.

I sincerely appreciate your help in the completion of my dissertation. If you are interested in the
final results, you are welcome to email me directly at ccrispen@usc.edu.

Thank you!

Christine Crispen
Rossier School of Education
Doctorate of Education, Education Leadership Program

Abstract (if available)

Abstract This study has focused on medical students and their experiences with racism, microaggressions, and their campus climate and how these may influence their journey and efficacy while in medical school. Specifically, the focus has been on the differences in these experiences between students who identify as underrepresented in medicine and those who do not.

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Asset Metadata

Creator Crispen, Christine Lynn (author)

Core Title The relationship between the campus climate and under-represented students’ experiences on campus and the influences on fit, self-efficacy, and performance: a qualitative study

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Publication Date 10/09/2017

Defense Date 08/30/2017

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

Tag campus racial climate,medical students,OAI-PMH Harvest,underrepresented in medicine

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Chung, Ruth (committee member), Combs, Wayne (committee member)

Creator Email ccrispen@usc.edu,christine.crispen@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-442298

Unique identifier UC11264132

Identifier etd-CrispenChr-5823.pdf (filename),usctheses-c40-442298 (legacy record id)

Legacy Identifier etd-CrispenChr-5823.pdf

Dmrecord 442298

Document Type Dissertation

Rights Crispen, Christine Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA