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The role of race and racism in Black male medical students’ specialty selection process

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The role of race and racism in Black male medical students’ specialty selection process

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The Role of Race and Racism in Black Male Medical Students’ Specialty Selection Process

Taku Taira

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

May 2023

© Copyright by Taku Taira 2023
All Rights Reserved

The Committee for Taku Taira certifies the approval of this Dissertation

Helena Seli
Eric A. Canny
Kimberly Hirabayashi, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
Black men experience racialization in medicine stretching from underrepresentation,
marginalization, to racial hostility. In contrast to national trends, they are more likely to pursue
the lowest paying jobs and in the least prestigious fields. This study employed qualitative
methodology through a critical race theory framework to understand the role of race and racism
in how Black men choose their specialty. Sixteen Black male medical students were interviewed
for this study. Participants described a variety of racialized experiences and forces that not only
shaped their decisions, but narrowed their choices. In their exploration of fields, they found
fields that were both racially welcoming and those that were specifically racially hostile.
Similarly, participants described racialized barriers to both connecting with mentors and
receiving adequate racially aware mentorship. While the official messaging to students was that
they should pick the fields they liked, participants described how they were pushed towards
primary care fields. This message was so ubiquitous that it created a sense of racial duty for
participants. While participants were able to resist internalizing these messages, they served as a
constant presence in their choices. This study not only revealed the racialized experiences,
pressures, and barriers to their free choices, it identified multiple points of intervention to address
the forces of systemic racism in Black men’s specialty choices.

v
Dedication
To my wife, Breena Taira, MD, MPH, I could not have achieved this without you. This work is a
testament to your sacrifice and support. You push me to achieve my full potential and
demonstrate what that looks like.

To my children, Lev and Sei, thank you for your patience and understanding. I hope that this
work lives up to what you had to give up.

vi
Acknowledgements
I would like to use this space to acknowledge several people who were essential to the
conceptualization and completion of this dissertation. I would first like to acknowledge my wife,
Breena Taira, MD, MPH, who has been an essential source of expertise and an irreplaceable
sounding board through the entirety of this dissertation. I would like to specifically recognize my
professors in the OCL program, Drs. Eric Canny, Doug Lynch, Deanna Campbell, and Courtney
Malloy, who collectively pushed me to think deeply and carefully. The work I did in their classes
was fundamental to this dissertation. I owe a deep debt to Drs. Darin Latimore, Alden Landry,
Jedan Phillips, Dowin Boatright, and Ricky Bluthenthal for their essential guidance in the
conceptualization and design of the research question.
This study was investigator funded. I have no personal or financial conflicts to report.
Please feel free to contact me with any questions or concerns you have about this publication. I
can be reached at takutair@usc.edu.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
Chapter One: Overview of the Study .............................................................................................. 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 5
Importance of the Study ...................................................................................................... 6
Overview of Theoretical Framework and Methodology .................................................... 6
Definition of Terms ............................................................................................................. 7
Organization of the Dissertation ....................................................................................... 12
Chapter Two: Literature Review .................................................................................................. 13
Evolution of the Rationale to Address Diversity in Medicine .......................................... 13
Racialization in Medicine ................................................................................................. 20
Gaps in the Literature ........................................................................................................ 27
Purpose Statement and Theoretical Framework ............................................................... 28
Justification ....................................................................................................................... 30
Conclusion ........................................................................................................................ 31
Chapter Three: Methodology ........................................................................................................ 32
Research Questions ........................................................................................................... 32

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Overview of Design .......................................................................................................... 32
Research Setting ................................................................................................................ 33
The Researcher .................................................................................................................. 33
Data Sources ..................................................................................................................... 35
Participants ........................................................................................................................ 36
Instrumentation ................................................................................................................. 36
Data Collection Procedures ............................................................................................... 36
Data Analysis .................................................................................................................... 38
Credibility and Trustworthiness ........................................................................................ 38
Ethics ................................................................................................................................. 39
Chapter Four: Findings ................................................................................................................. 41
Participants ........................................................................................................................ 41
Research Question 1 ......................................................................................................... 45
Research Question 2 ......................................................................................................... 88
Summary ........................................................................................................................... 93
Chapter Five: Discussion and Recommendations ......................................................................... 95
Findings ............................................................................................................................ 95
Recommendation for Practice 1: Increase the Capacity for Black Medical Student
Mentorship Through the Training of Cross-Racial Faculty ............................................ 103
Recommendation for Practice 2: Strengthen and Solidify Peer-Mentorship .................. 106
Recommendation for Practice 3: Address Mentee-Based Barriers to Mentorship
Through Pre-Matriculation Programs ............................................................................. 108

ix
Limitations and Delimitations ......................................................................................... 109
Recommendations for Future Research .......................................................................... 110
Conclusion ...................................................................................................................... 111
References ................................................................................................................................... 113
Appendix A: Interview ............................................................................................................... 156
Appendix B: Recruiting Participants .......................................................................................... 159

1
Chapter One: Overview of the Study
There is a persistent problem of diversity, equity, and inclusion (DEI) in medicine.
Persons who are underrepresented in medicine (URiM) contend with an educational and
professional environment that is marked by racial exclusion and inequity (Osseo-Asare et al.,
2018). They face racialized barriers and hostility starting from entry and continuing through their
educational and professional career. These barriers and experiences have persisted despite
increased awareness and acknowledgement of the importance of DEI.
Despite the concerted efforts by multiple organizations (Association of American
Medical Colleges [AAMC], 2015; Nickens et al., 1994), racial underrepresentation in medical
schools has persisted (AAMC, 2022). This underrepresentation in undergraduate medical
education (UME) is magnified by a racialized distribution among the medical specialties. URiM
students preferentially pursue training in the primary care fields (Brotherton & Etzel, 2020;
National Resident Matching Program [NRMP], 2019; Xierali et al., 2014), leading to persistent
underrepresentation in fields such as orthopedics (Lin et al., 2020). While there have been
studies on how medical students choose their specialties (Borges & Savickas, 2002; Donnellan et
al., 2006; Rogers et al., 2011; Stratton et al., 2005; Vaidya et al., 2004), the causes of this
racialized distribution are not well understood.
It is important to specifically focus on the experiences of Black men. Although there have
been slight gains in Black/African American medical student representation (Acosta et al., 2017),
these are predominantly the result of gains in Black female representation (AAMC, 2019a). In
comparison, Black male representation has been stagnant since 1978 (AAMC, 2015). Although
there is a recognition of this racially gendered problem (AAMC, 2015; Laurencin & Murray,
2017), there is a gap in the literature investigating the potential causes and interventions.

2
As the medical specialties move to address diversity in their fields and realize its benefits
(American Academy of Ophthalmology, n.d.; American Academy of Orthopaedic Surgeons,
n.d.; American Academy of Pediatrics, n.d.; American Board of Internal Medicine, n.d.;
American College of Emergency Physicians, n.d.; American College of Obstetrics and
Gynecologists, n.d.; American College of Surgeons, n.d.; American Neurological Association,
n.d.; Psychiatry.Org, n.d.), there is an increased need to understand the causes and contributing
factors to this racialized distribution. It is especially important to understand this phenomenon
among Black men, whose representation has continued to lag their racial and gender peers. This
investigation seeks to center and amplify Black male voices to understand the role of race,
racism, and gender in their career decisions.
Context and Background of the Problem
Efforts to address underrepresentation of URiM students and physicians has paralleled
broader racial awareness in the United States. Initial efforts to recruit students of color were an
outgrowth of the racial awareness stemming from the civil rights movement (Sullivan & Suez
Mittman, 2010). These efforts initially culminated in the desegregation of medical schools in
1966. Desegregation was followed by concerted efforts to increase the racial and ethnic diversity
of medical schools (Nickens et al., 1994). These efforts have continued by interventions by
individuals, local organizations (Johnson et al., 1998; Smith et al., 2009; Talamantes et al., n.d.;
Tour for Diversity in Medicine, n.d.), and national governing bodies (AAMC, n.d.-a;
Accreditation Council for Graduate Medical Education n.d.-a; Liaison Committee on Medical
Education, n.d.).

3
The movement and the justification to address underrepresentation in medicine has
gradually evolved. During the civil rights era, the movement towards diversity focused on
reverse previous injustices and exclusion (Sullivan & Suez Mittman, 2010). There has been a
gradual recognition of the benefits of diversity that include positive effects on medical education
(Addams et al., 2010; AAMC, 2019c; Coleman et al., 2014; van Schaik et al., 2019) and clinical
care (Hagiwara et al., 2016, 2017; Malat & Hamilton, 2006; Stepanikova et al., 2012). The
benefits extend beyond the individual institutions. On a national level, physician diversity is
increasingly seen as a key component to address racial and socioeconomic health disparities
(Cohen & Steinecke, 2006; Institute of Medicine of the National Academies of Science, 2003;
Kelly-Blake et al., 2018; Komaromy et al., 1996; Marrast et al., 2014; Saha, 2015). This
understanding has led to a shift from a movement centered on a moral imperative to a movement
driven by a desire to actualize the benefits of diversity in medicine (Addams et al., 2010;
Coleman et al., 2014).
Despite continual and concerted efforts at the local and national level,
underrepresentation persists. After a rapid increase in representation in the 1970s, there has been
minimal progress in racial and ethnic representation in medicine (Lett et al., 2019). In 2021,
Black/African American, Hispanic, American Indian/Alaskan Native, and Native
Hawaiian/Pacific Islander were 34% of the U.S. population (U.S. Census Bureau, n.d.), but only
20% of medical school matriculants (AAMC, 2022).
URiM students are not a monolithic group. While there has been steady progress in
URiM enrollment and representation in medical schools (AAMC, 2019a; Acosta et al., 2017),
this progress has not been uniform. In contrast to this greater trend, from 1978 to 2015 there was
a decrease in the number of Black male applicants and matriculants to medical school (AAMC,

4
2015). Although there have been slight increases in Black/African American medical student
representation (Acosta et al., 2017), these gains are predominantly attributable to progress in
Black female representation (AAMC, 2019a). In 2019 Black men accounted for 1/3 of Black
matriculants, compared to gender parity among Asian, LatinX, and White medical students
(AAMC, 2019a). While there is a recognition of this racially gendered problem (AAMC, 2015;
Laurencin & Murray, 2017), there is a gap in the literature identifying the potential causes and
points of interventions.
The issue of racialization is not limited to admission and matriculation. There is a parallel
racialized distribution in the medical specialties. URiM students are nearly ten percent more
likely to pursue training in the primary care fields when compared to their White colleagues
(Brotherton & Etzel, 2020; NRMP, 2019; Xierali et al., 2014). This racialized distribution runs
counter to a national and international trend for students to pursue specialization instead of
primary care (Bennett & Phillips, 2010; Blades et al., 2000; Jordan et al., 2003; Lawson &
Hoban, 2003; Scott et al., 2009). At the same time, they are generally absent from the most
competitive specialties. In 2020, 7.8% of family medicine (FM) residents were Black while 1.7%
of ophthalmology residents and 2.4% of ENT residents were Black compared to a baseline
representation on 5.6% (Brotherton & Etzel, 2020).
The uneven racial distribution among the specialties occurs within the context of
increasing stratification of the medical specialties. Specialties vary in their stratification across
multiple dimensions. Highly competitive fields, such as neurosurgery or ophthalmology, are not
only perceived as the most prestigious (Norredam & Album, 2007), they also have the most
competitive residency application (Faber et al., 2016; NRMP, 2019). In contrast, the primary
care fields are perceived as less prestigious (Creed et al., 2010; Norredam & Album, 2007) and

5
less competitive (Faber et al., 2016). However, these differences extend beyond perceptions and
are reflected in the differences in salary. The average salary for a neurosurgeon is nearly
$800,000 compared to just over $200,000 for a family physician (Faber et al., 2016).
The racialized distribution of URiM students to the fields perceived as least prestigious
with the lowest compensation highlights a racial educational and economic inequity in medical
education. While there have been studies on medical students’ specialty selection (Borges &
Savickas, 2002; Donnellan et al., 2006; Rogers et al., 2011; Stratton et al., 2005; Vaidya et al.,
2004), none of these focused on URiM students’ decisions. It is unclear if URiM students are
actively choosing to pursue primary care fields or if they are funneled through coercion and
exclusion. This raises the need for an investigation into the role of systemic racism in creating
this racially differential outcome.
Purpose of the Project and Research Questions
The purpose of this study is to both understand Black male medical students’ specialty
selection and the role of race and racism in that process. Doing so will not only deepen the
understanding of the lived experiences of Black males in medical school, but uncover the hidden
forces of systemic racism. This will hopefully be the basis for identifying points of intervention
for groups and individuals who are working to not only increase the representation of Black
males in their specialties and organizations, but to address the sense of inclusiveness in their
environments. The following research questions will guide this study.
1. What are the critical experiences of Black male medical students in choosing a
specialty?
2. How do Black male medical students negotiate conflicts between internal and
external expectations regarding their specialty selection?

6
Importance of the Study
This study fills multiple gaps in the literature. While there have also been studies to
understand how students make their decisions about their specialty (Borges & Savickas, 2002;
Jarecky et al., 1993; Rogers et al., 2011; Stratton et al., 2005; Vaidya et al., 2004), there is a lack
of literature investigating the persistent racialized distribution of URiM students into primary
care fields (Brotherton & Etzel, 2020). Black students within the medical specialties. This is
important for both individuals and institutions who want to support Black male medical students
but also for those who are looking to increase the representation of Black men in their field.
While there have been studies investigating Black representation in medicine (AAMC, 2015;
Morrison & Cort, 2014; Rao & Flores, 2007; Thomas et al., 2011), the differential attainment
among Black men (AAMC, 2015, 2022), highlights the need for a specific focus on Black men.
Overview of Theoretical Framework and Methodology
The purpose of this study is to uncover how Black medical students choose their
specialties. I will employ critical race theory (CRT) as the theoretical foundation to understand
this process. This theoretical foundation will not only allow this research to progress in a manner
that centers on Black male voices, but also uncover the role that race and racism play in shaping
this process.
CRT starts from the understanding that racism is ubiquitous and pervasive (Ladson-
Billings, 1998). Because of its pervasiveness, racism is built into the values and assumptions in
our systems, and manifest and shape nearly all points of contact through the medical educational
environment. This systemic racism in turn acts upon minoritized individuals to create differential
outcomes (Cabrera, 2019; Ladson-Billings & Tate, 2018; Stovall, 2013). CRT stands in
opposition to the deficit model, which explains inequalities by “blaming” the students for their

7
deficits (Cabrera, 2019). CRT instead centers on the minoritized individual and uses their
(counter) stories to uncover the, often hidden, assumptions that systemic racism is built upon
(Bronner, 2011; Ladson-Billings, 1998).
Centering on the Black male medical students’ experience will allow this study to focus
on their experience and their decision making. In doing so, I hope to illuminate how race and
different forms of racism shape these experiences and decisions. This study is built upon the
theory of change that an empirical counter-narrative will not only illuminate the Black male
experience, but also uncover hidden barriers. This counternarrative will not only deepen our
understanding, but also serve as a roadmap to drive systematic change.
I will conduct a qualitative study investigating how Black male medical students choose
their specialty. I will conduct in-depth semi-structured interviews with Black male medical
students from allopathic U.S. medical schools. Interviews will be transcribed verbatim and
analyzed iteratively. Analysis will be informed by the constant comparative analysis approach.
Sampling will be continued until there is thematic saturation.
Definition of Terms
This section provides the definition of key terms related to this study.
• Accreditation Council for Graduate Medical Education (ACGME) is the accrediting
body for graduate medical education residency and fellowship training programs
(Accreditation Council for Graduate Medical Education, n.d.-b). They provide
accreditation on both the institutional and individual program levels.
• Association of American Medical Colleges (AAMC) is the national association of U.S.
medical schools, teaching hospitals, and academic medical centers (AAMC, n.d.-b).
The AAMC administers the medical college admission test (MCAT; AAMC, n.d.-c),

8
which is required for most medical school applications. They also operate the
American Medical College Application Service (AMCAS; AAMC, 2019b) for
medical school applicants. They also administer the Electronic Residency Application
Service (ERAS; AAMC, n.d.-c), which is the application service for most residency
applicants. They also co-sponsor the Liaison Committee on Medical Education
(LCME; Liaison Committee on Medical Education, n.d.-a), which is the accreditation
body for medical schools.
• Competitive specialties are the specialties that have the greatest requirements for
applicants. They employ the highest cut-offs for performance on both standardized
exams and in medical school (Faber et al., 2016; Fung & Lui, 2020; National
Residency Matching Program, 2020). They have the lowest percentage of both
osteopathic and graduates from foreign medical schools (Brotherton & Etzel, 2020;
Fung & Lui, 2020). Although there is no specific designation, dermatology,
neurosurgery, ophthalmology, otolaryngology (ENT), and urology are commonly
accepted as being highly competitive.
• Fellowship and subspecialty training refer to further clinical training beyond initial
residency training (American College of Physicians, n.d.; AAMC, n.d.-d). Fellowship
and subspecialty training are synonymous terms. Fellowships are further
specialization within a specific field. Fellowship training requires the completion of
training in the broader field, e.g., cardiology requires the prior completion of internal
medicine, and a retina fellowship requires prior training in ophthalmology. In a
minority of fields, residency and fellowship are combined into a single training
program.

9
• Graduate medical education (GME) refers to the branch of medical education that
follows the graduation from medical school, but excludes continuing medical
education (CME; Accreditation Council for Graduate Medical Education, n.d.-b).
GME encompasses training in residency as well as sub-specialties. GME only refers
to training that relates to medical care and does not include additional training in
fields such as research or advocacy.
• Historically black colleges and universities (HBCU) refer to the universities whose
mission is to educate Black Americans (U.S. Department of Education, n.d.). HBCUs
are an example of a minority serving institution (MSI).
• Internalized racism/self-stereotyping is the response of accepting and internalizing
pervasive negative racial stereotypes as true (Williams et al., 2019).
• (The) match refers to the process by which students are matched to a specific
residency training program (National Residency Matching Program, n.d.). This is the
culmination of students applying and interviewing at individual residency programs.
The match is open to allopathic, osteopathic, and graduates of foreign medical
schools. It is administered by the independent National Residency Matching Program
(NRMP).
• Medical specialty (commonly shortened to “specialty”) refers to the area of medicine
in which a physician practices (Accreditation Council for Graduate Medical
Education, n.d.-b; American College of Physicians, n.d.; Kalter, 2018). These
encompass a wide variety of medicine, ranging from generalists to specialists who
focus on the function of a single organ. These also include the surgical and non-
surgical fields.

10
• Minority serving institution (MSI) refers to institutions of higher learning that
specifically serve minority populations. MSIs include HBCUs, Hispanic-serving
institutions (HSI), and Asian American and Pacific Islander serving institutions
(AAPISIs; Minority Serving Institutions Program, U.S. Department of the Interior,
n.d.).
• Program director (PD) is the director for a specific residency training program
(Accreditation Council for Graduate Medical Education, 2022). They are all
practicing physicians in their respective specialties. PDs are not only responsible for
the administration of the residency training program, but they are also responsible for
the recruitment and selection process for the training program.
• Primary care refers to the practice(s) of medicine that focuses on the large proportion
of a patient’s health care needs (Kalter, 2018). The fields that are generally accepted
as being primary care include family medicine, OB/GYN, general internal medicine,
and general pediatrics. Primary care fields do not include sub-specialties of internal
medicine, pediatrics, OB/GYN, and family medicine. Surgical fields are not
considered primary care.
• Racial microaggressions are “brief and common place daily verbal, behavioral, or
environmental indignities, whether intentional or unintentional, that communicate
hostile, derogatory, or negative racial slights and insults toward people of color” (Sue
et al., 2007).
• Residency training is the clinical training specific to the medical specialty that the
person is pursuing. Residency training ranges in length and competitiveness.
Residency training requires prior completion of either allopathic or osteopathic

11
medical school. Residency training is a prerequisite to practicing clinical medicine in
the United States (Accreditation Council for Graduate Medical Education, n.d.-b).
• Stereotype threat is the fear of confirming a negative stereotype about one’s group
which in turn leads to decreased performance (Godsil et al., 2018).
• Systemic racism is the policies and procedures that serve to maintain White privilege
(Bell, 2008; Ladson-Billings, 2018).
• Unconscious/dysconscious racism is defined as “a disposition whereby people adapt
implicitly or explicitly to injustice” (King, 1991).
• Underrepresented in medicine (URiM) refers to racial and ethnic groups suffering
from underrepresentation in medicine (AAMC, n.d.-e).
• Undergraduate medical education (UME) refers to the education within medical
school. This includes both pre-clinical and clinical training. UME is inclusive of both
allopathic (MD) and osteopathic (DO) medical training (American Association of
Colleges of Osteopathic Medicine, n.d.; AAMC, n.d.-b).
• United States Medical Licensing Examination (USMLE) is a series of three
examinations, also known as step 1, 2, and 3, that are a prerequisite to medical
licensure in the United States (United States Medical Licensing Examination, n.d.).
Step 1 is typically taken at the end of the pre-clinical curriculum (years one and two)
in a 4-year U.S. medical school. Step 2 is typically taken in the 4th year of medical
school after the completion of the core clinical curriculum. Step 3 is taken in the 1st
post-graduate year, typically the intern year of residency. These exams are commonly
referred to as “step.”

12
Organization of the Dissertation
This dissertation will be divided into five chapters. This chapter serves as an introduction
and overview of the problem of underrepresentation in medicine and the specific gap in the
literature that this study is attempting to address. Chapter Two will provide a review of the
literature as well as introduce the conceptual framework of the study. Chapter Three will
describe and outline the methodological approach to inquiry, the participants, and the rationale
for these choices. Chapter Four will describe the findings of the study. Chapter Five will serve as
the discussion of the findings as well as an opportunity to discuss the recommendations for
practice.

13
Chapter Two: Literature Review
In this chapter I will provide an overview of the history, the evolution, and the current
state of diversity, equity, and inclusion (DEI) in medicine. Within this I will provide a nuanced
picture that goes beyond a description of underrepresentation, but includes a description of the
racial environment in medicine and the experiences of minoritized individuals. Finally, I will
identify the gaps in the literature, highlighting the importance of focusing on the experiences of
Black men in medicine and the importance of understanding how they make their decisions
about their specialties.
Evolution of the Rationale to Address Diversity in Medicine
There is a problem of persistent racial underrepresentation in medicine. Before 1964,
93% of medical students were male and 97% were non-Hispanic White (Nickens et al., 1994).
Despite the integration of medical schools, elimination of explicit exclusionary practices, and
broad national interventions, Black, Hispanic, and Native American/Alaskan Native students
continue to be underrepresented compared to their proportion of the population (AAMC, 2022;
U.S. Census Bureau QuickFacts: United States, n.d.).
Underrepresentation in medicine has not only persisted, but diversity initiatives in higher
education have increasingly faced vocal opposition (Bonilla-Silva, 2008; Harper, 2012; Kidder et
al., 2004; Pew Research Center, 2019; Supremecourt.gov, 2022; Vertovec & Wessendorf, 2009).
Groups such as Students for Fair Admissions are focused on eliminating the legal protection of
the consideration of race in college admissions (Students for Fair Admissions, n.d.). While the
issue of affirmative action has increasingly been politicized, as demonstrated by the Trump
administration’s memorandum banning training in CRT (Whitehouse & Vought, 2020). Both the

14
legal and political opposition to diversity initiatives have created a pressure for the evolution of
the justification for addressing underrepresentation in medicine across decades.
Early interventions to address diversity in medicine arose out of the racial consciousness
of the civil rights movement (Nickens et al., 1994). This social justice perspective centered its
interventions to address racial diversity on a moral need to remedying past racial injustices
(Coleman et al., 2014; Dwertmann et al., 2016). This perspective is exemplified by the critical
race theorists (Bell, 1980; Ledesma & Calderón, 2015; Yosso, 2002). These early interventions
had broad-based support and were well funded by both the federal government and private
foundations (Nickens et al., 1994).
Since the post-civil-rights era, there have been several major influences that moved the
justification for diversity from a moral and/or social justice perspective to a productivity
perspective that centers on actualizing the benefits of diversity. Public backlash to affirmative
action and its associated legal challenges narrowed how race was considered in admission and
hiring (Coleman et al., 2014; Ledesma, 2013; Lee, n.d.; Lehman, 2010). In 1978, the Supreme
Court found the UC Davis medical school’s affirmative action program to be unconstitutional,
but acknowledged the constitutionality of the consideration of race in situations where the
organization can justify that if it is “narrowly tailored” and serves a “compelling interest”
(O’Neill, 2008). The Supreme Court has subsequently upheld the consideration of race in
admissions in 2003, 2007, and 2013 (Coleman et al., 2014). Although this preserved the ability
for organizations to consider race in admissions, it created a need for medical schools to be
deliberate about their justification for addressing medical school racial diversity.

15
The need for deliberate justification for the consideration of race in admissions coincides
with the growing recognition of racial/ethnic, social, and economic health disparities,
culminating in the publication of the influential Institute of Medicine (IOM) report “Unequal
Treatment” in 2003(Institute of Medicine of the National Academies of Science, 2003). Health
disparities are defined as health differences linked to a social, economic, and/or environmental
disadvantage (Centers for Disease Control, n.d.). In the United States, ethnic and racial
minorities suffer greater incidences of health-related conditions ranging from diabetes, HIV
infection, heart disease, and hypertension (Betancourt, 2003; Centers for Disease Control [CDC],
2013). They not only have lower access to health care (Agency for Healthcare Research and
Quality, 2013; Andrulis, 1998; Blendon, 1989; Chen et al., 2016; Cohen et al., 2002; Komaromy
et al., 1996), what care they receive is of poorer quality (Agency for Healthcare Research and
Quality, 2011; Bach et al., 2004; Centers for Disease Control [CDC], 2013; Betancourt, 2003).
These differences were highlighted by racial and ethnic differences in rates of infection (Baltrus
et al., 2021; Gaynor & Wilson, 2020; Gold et al., 2020; Millett et al., 2020), severity of disease
(Keifer & Effenberger, 2021), and likelihood of death (Gross et al., 2020; Haynes et al., 2020;
Yancy, 2020).
The broader recognition health disparities and the imperative to address them came at the
same time as a broader recognition of the benefits of diversity in medicine. There was an
increasing body of literature that recognized that way in which URiM physicians were already
directly and indirectly addressing many of these shortcomings. This led people to identify

16
physician diversity as not only a central component to the problem of health disparities, but a
“compelling interest” that aligned with the medical school missions (Coleman et al., 2014).
Access to Care
Differential access to care is a major component to health disparities. Access to
physicians is inversely related to socioeconomic status (SES) of the community (Kindig &
Movassaghi, 1989) and the number of Black and Hispanic residents (Cohen, 2003; Komaromy et
al., 1996). This correlation of SES and race additionally means that even if minority patients can
access care, they may not be able to afford the care that they need (Andrulis, 1998), leading to
delays in care, more costly care, and increased morbidity and mortality (Institute of Medicine of
the National Academies of Science, 2003).
At the same time, it is important to note that URiM physicians are more likely to care for
these same populations that are more likely to encounter barriers to access medical care (Bach et
al., 2004; Cregler et al., 1997; Goodfellow et al., 2016; Gugelchuk & Cody, 1999; Johnson et al.,
1989; Ko et al., 2007; Komaromy et al., 1996; Labbe et al., 2018; Lupton et al., 2012; Marrast et
al., 2014; Moreno et al., 2011; Moy & Bartman, 1995; O’Connell et al., 2018; Polsky et al.,
2002; Rabinowitz et al., 2000; Walker et al., 2010, 2012; Wilbur et al., 2020; Yoon et al., 2004).
When compared to their White counterparts, URiM physicians are more likely to care for
racial/ethnic minorities (Komaromy et al., n.d.; Marrast et al., 2014), patients with limited
English proficiency (LEP; Institute of Medicine of the National Academies of Science, 2003;
Marrast et al., 2014; G. Moreno et al., 2011; Moy & Bartman, 1995), and low-
income/Medicaid/uninsured (Bach et al., 2004; Blendon, 1989; Brotherton et al., 2000;
Komaromy et al., 1996; Marrast et al., 2014; Moy & Bartman, 1995; O’Connell et al., 2018;
Perez, 2006; Xierali & Nivet, 2018). Even when compared to factors that would likely correlate

17
with caring for underserved populations, such as physician SES and participation in the National
Health Service Corps, identification as a URiM physician is a better predictor for caring for the
underserved (Saha & Shipman, 2008).
Quality of Care
The URiM physician’s ability to improve the quality of care centers on their ability to
improve racially concordant care. As a group, minoritized patients have a different relationship
with the health care system. They report greater degrees of perceived discrimination and mistrust
in both the health care system and their physicians (Blendon, 1989; Dovidio et al., 1993;
Hausmann et al., 2013; LaVeist et al., 2000; Malat & Hamilton, 2006; Sewell, 2015; Stepanikova
et al., 2012). They report less partnership with physicians (Johnson et al., 2004; Kaplan et al.,
1995) and lower levels of satisfaction with care (Cooper-Patrick et al., 1999; Kaplan et al., 1995;
Saha et al., 1999). Communication between racially discordant patient-physician dyads are
marked by less involvement in medical decisions (Cooper-Patrick et al., 1999; Kaplan et al.,
1995), lower degree of patient-centeredness (Hagiwara et al., 2017; Johnson et al., 2004), and
distant affect and verbal dominance by the physician (Cooper et al., 2012; Johnson et al., 2004).
Understandably, these contribute to poorer compliance with care plans (Altice et al., 2001;
Schneider et al., 2004; Schoenthaler et al., 2014) and less physician-patient continuity (Mainous
et al., 2001).
In contrast, racially concordant dyads have visits that are longer, more participatory
(Cooper et al., 2003), have a greater positive patient affect (Cooper et al., 2003; Stepanikova et
al., 2012), and are associated with greater patient satisfaction (Cooper et al., 2003; LaVeist &
Carroll, 2002; Nápoles-Springer et al., 2005; Saha et al., 1999; Takeshita et al., 2020). The
positive effects are not limited to perceptions and satisfaction. Patients in racially concordant

18
dyads have improved compliance with treatment (Barr et al., 2008; LaVeist & Carroll, 2002;
Silver et al., 2019; Traylor et al., 2010), improved blood pressure control (Schoenthaler et al.,
2014), improved participation in routine health screening (Alsan et al., 2019), and are less likely
to delay seeking care (LaVeist & Carroll, 2002; Saha et al., 1999). Given these positive effects, it
should not be surprising that minoritized populations prefer to be seen by racially concordant
providers (LaVeist & Carroll, 2002; LaVeist & Nuru-Jeter, 2002; Saha et al., 2000; Snyder &
Truitt, 2020).
Even though URiM physicians are more likely to serve minority populations (Komaromy
et al., 1996; Marrast et al., 2014; Saha et al., 1999), the need for URiM physicians continues to
exceed the supply. Despite patients’ preferences, only around 23–25% of Black and LatinX
patients are in racially concordant dyads (LaVeist & Carroll, 2002; Schnittker, 2006). This
difficulty not only highlights the differential access to care, but also the need for more URiM
physicians.
Medical Education
The advantages of physician diversity exist from both the patient and medical education
perspective. Beyond the positive influence on clinical care, diversity has the potential to improve
medical education and address their curricular needs. Since the adoption of LCME accreditation
standards for cultural competency in medical education in the year 2000 (LCME, n.d.), medical
schools have worked to implement curricula on cultural competence (AAMC, 2005). This shift
occurred simultaneously with a change in the workplace that has placed a greater emphasis on
cultural competence (Betancourt, 2003); Betancourt et al., 2005; Johnson et al., 2004). Shifting
racial demographics, social movements, and ongoing difficulty in cross-racial patient-physician

19
trust and communication (Dovidio et al., 2008; LaVeist et al., 2000; Malat & Hamilton, 2006;
Stepanikova et al., 2012) highlight the need for physicians to be prepared to care for patients
across the racial, ethnic, social, and socioeconomic spectrum (Betancourt, 2003; Betancourt et
al., 2005).
Increased student racial diversity has the potential to address these needs. Racial diversity
is positively associated with a student’s ability to learn from others across racial and social
differences (Bowen, 2000; Chang, 1999; Chang et al., 2006; Pike et al., 2007; Pike & Kuh, 2006;
Saha, 2015; Umbach & Kuh, 2006), as well as lead to improved academic and social self-
concepts, lower levels of prejudice, and increased perspective taking skills (Bowman et al., 2011;
Engberg & Hurtado, 2011; Hurtado, 2007; Hurtado & DeAngelo, 2012). Notably, the positive
effects of cross-cultural interactions are stronger than the effects of diversity course work
(Bowman et al., 2011).
Although it is difficult to link medical school diversity with culturally competent care or
patient-centered outcomes, increased student body diversity is associated with student reports of
preparedness to care for minority populations (Saha et al., 2008). Across all medical schools,
89% of students report that they were positively influenced by differing perspectives and that
diversity enhanced their medical school training (AAMC, 2019c). These findings suggest that
increased student diversity has the potential to improve medical education, and it has the
potential to affect downstream care for minoritized patients beyond the increase in the number of
URiM physicians.

20
Racialization in Medicine
Despite widespread affirmations about the importance of diversity, equity, and inclusion,
from the URiM perspective medicine and medical education continue to be racialized. The
URiM and non-URiM experiences diverge across multiple domains, ranging from the tangible
underrepresentation to the internal experience of microaggressions. Examples include racially
differential expectations, evaluations, and access to opportunities. The result is differential
attainment at the student, resident, and faculty levels.
Racial Underrepresentation
The most visible and tangible form of racialization is underrepresentation. The
Association of American Medical Colleges (AAMC) defines Underrepresented in Medicine
(URiM) as “racial and ethnic populations that are underrepresented in the medical profession
relative to their numbers in the general population” AAMC. (n.d.-e). Individuals who identify as
Black/African American, Hispanic, American Indian/Alaskan Native, and Native
Hawaiian/Pacific Islander are broadly identified as being URiM. In 2021 these groups
represented 34% of the U.S. population (U.S. Census Bureau, n.d.), but only 11% of current
physicians and surgeons (AAMC 2019a). This is echoed by underrepresentation of medical
school applicants, matriculants, and graduates (AAMC. 2019a), residents (Brotherton & Etzel,
2020), and medical school faculty (Xierali et al., 2016).
Although there has been progress in racial/ethnic underrepresentation, progress has been
uneven. After the civil rights movement and the integration of medical schools, minority
matriculation in medical schools rose from 0.5% in 1964 to 10 percent in 1974 (Reede, 2003).
However, from 1974 to 1990 there was no growth in URiM representation despite a proportional

21
increase in theU.S. population (Institute of Medicine, 2004). A similar trend is seen in the “3000
by 2000” campaign (Nickens et al., 1994), which was successful in creating an educational
pipeline program but was unable to create sustained improvements in underrepresentation
(AAMC, 2015; Butts et al., 2008; Cohen, 2003).
There is mixed data about how much progress has been made in underrepresentation in
the post-civil rights era. From 1980 to 2016, URiM medical student matriculation increased by
3344 URiM positions (AAMC, 2019a). While this represents an absolute increase in the number
of URiM students, not only does it lag demographic shifts (Xierali, Castillo-Page, et al., 2014), it
is mostly attributable to the outsized effect of new medical schools that attract and accept a
higher percentage of URiM students and not a systematic change (Shipman et al., 2013).
The problem of underrepresentation among medical school faculty is even greater than
what is seen among the medical students. Racial underrepresentation is further magnified among
medical school faculty. Medical school faculty diversity has not kept pace with medical student
diversity (Xierali et al., 2016). While 7% of medical students are Black/African American, 3.6%
of medical school faculty are Black (AAMC, 2019a). Of the Black/African American faculty,
they are predominantly concentrated at the junior ranks of the faculty (Xierali et al., 2016),
accounting for 1.5% of the faculty at the rank of professor (AAMC, 2016).
Disaggregating Data About Gender and Race
Progress in female representation stands in stark contrast to progress in racial/ethnic
representation. In 1980, women accounted for 30% of all medical school applicants, but reached
gender parity in 2003 (AAMC, 2019a). In 2019 women represented most medical students
(AAMC, 2019a) and 55% in 2022 (AAMC, 2022). The ability of the medical education system

22
to reach gender parity proves that it has the ability and capacity to address racial and ethnic
underrepresentation.
It is important to examine data about Black and Hispanic students and physicians
separately. Although there is a tendency to treat URiM experiences, challenges, and progress as
monolithic, there is data to suggest important differences. Progress among Hispanic individuals
has surpassed Black progress in both absolute terms and in proportion to the population. From
2012 to 2017, Hispanic medical student relative representation increased by 64% compared to a
7% relative increase in Black representation (Boatright et al., 2018). During a similar period,
Hispanic female medical school applicants increased relative to the population compared to a
decrease among Black women and stagnation among Black men. Similarly, the acceptance rate
of 42% for Hispanic applicants is statistically equivalent to the rates for Asian, American
Indian/Alaska Native, and White, but higher than the rate of 35% for Black applicants (Acosta et
al., 2017).
Black Men in Medicine
Within the discussion about representation, it is important to identify Black men as
outliers. While there has been modest growth in Black medical school enrollment, it is largely
attributable to gains by Black women (AAMC, 2019a, 2022). Currently Black women account
for 60% of Black medical school applicants and 63% of Black matriculants (AAMC, 2022). In
comparison, there is gender parity among applicants that identify as American Indian/Alaskan
Native, 47.7%, and Hispanic, 49.7% (AAMC, 2022).While there has been a steady increase in
Black male college graduation (Census.gov, 2022), Black male medical school applicants and
matriculants have not kept pace. In 1978 there were 1,410 Black male applicants and 542
matriculants, while in 2014 there were 1,337 Black male applicants and 515 matriculants

23
(AAMC, 2015). This is even though there has been a 35% annual increase in medical school
enrollment (AAMC, 2021).
While there is a need to address DEI broadly, both the relative lack of growth and the
persistence of this problem place Black men in the position of being left further behind.
Although there is both literature describing this racially gendered difference (AAMC, 2015;
Laurencin & Murray, 2017) and organizations that are working to reverse this trend, there is a
clear need for need for more (AAMC, 2015; Black Men in Medicine, n.d.; Student National
Medical Association, n.d.; Tour for Diversity in Medicine, n.d.). There is a need for literature
that centers on Black men, that not only focuses on understanding the issue but also on
developing interventions.
Racial Reality of the Educational, Training, and Professional Environment
Racialization does not end with admission—it continues in the educational, training, and
professional environment in medicine. As the saying goes “admission is not enough” (Jones et
al., 2021). Rather than an inclusive and equitable environment, medicine is often experienced as
racially hostile (Orom et al., 2013). URiM students, residents, and faculty report being negatively
impacted by racial discrimination, racial prejudice, feelings of isolation, and difficulty with
cross-racial communication (Carr et al., 2007; Dyrbye et al., 2007; Hassouneh et al., 2014; Hunt
et al., 2003; Mahoney et al., 2008; Nunez-Smith et al., 2009; Peterson et al., 2004; Pololi et al.,
2010).
The hostility is described as ubiquitous. URiM students, residents, and faculty describe
how they are subjected to racial hostility from patients (Acosta & Ackerman-Barger, 2017;
Liebschutz et al., 2006; Montenegro, 2016; Okwerekwu, 2016; Olayiwola, 2016; Osseo-Asare et
al., 2018), staff (Osseo-Asare et al., 2018; Pololi et al., 2010), colleagues (Hassouneh et al.,

24
2014; Peterson et al., 2004; Pololi et al., 2010), and faculty leadership (Carr et al., 2007; Peterson
et al., 2004). URiM individuals experience this hostility in an environment that is experienced as
unsupportive (Orom et al., 2013; Osseo-Asare et al., 2018; Wong et al., 2013). While the
hostility is exemplified by micro- and macro-aggressions, the racial hostility is reinforced by
leadership and colleagues who fail to respond (Liebschutz et al., 2006; Okwerekwu, 2016;
Osseo-Asare et al., 2018).
This racial hostility is not limited to their perceptions. URiM students receive lower
clinical evaluations (Lee et al., 2007). Their narrative evaluations are less likely to use
“standout” words and are more likely to be described as “competent” (Ross et al., 2017). URiM
students are less likely to be selected to medical honor societies even after adjusting for
performance (Boatright et al., 2017; Wijesekera et al., 2019). White researchers are twice as
likely to receive NIH grant funding when compared to Black researchers (Ginther et al., 2011,
2012) and are less likely to hold administrative or leadership positions (Nivet et al., 2008).
The accumulation of inequity and hostility understandably results differential outcomes.
URiM residents are 30% more likely to withdraw from residency and eight times more likely to
take extended leaves of absences than their White colleagues (Baldwin et al., 1995). Similarly,
URiM faculty report lower career satisfaction (Cohen et al., 1998; Fang et al., 2000; Nunez-
Smith et al., 2009; Palepu et al., 2000; Peterson et al., 2004; Price et al., 2005) and have a higher
percentage of faculty who are planning on leaving academic medicine (Palepu et al., 2000).
URiM faculty are less likely to be promoted (Fang et al., 2000; Palepu et al., 1998, 2000), and, as
a result, they are concentrated at the lower levels of assistant professor or clinical instructor
(Xierali et al., 2016).

25
Racialized Distribution of Physicians Among the Specialties
Although there is widespread commitment to addressing diversity among all medical
specialties, racialization extends into, and persists into, URiM specialty selection. URiM students
are 10% more likely to pursue training in the primary care fields than their White colleagues
(Rayburn et al., 2016; Xierali, Nivet, et al., 2014; Xierali & Nivet, 2018; Xierali, Castillo-Page,
Conrad, & Nivet, 2014; Zhang et al., 2015). At the same time, they are relatively
underrepresented in the most competitive fields. In 2019, 5.7% of all residents in training were
Black. In the primary care fields, their representation was 7.8% (family medicine), 6.2% (internal
medicine), 8.2% (OB/GYN), and 6.7% (pediatrics). In contrast, in the highly competitive fields
they accounted for 4.5% (dermatology), 4.4% (neurosurgery), 1.7% (ophthalmology), 2.4%
(ENT), 3.4% for urology (Brotherton & Etzel, 2020). The 1.7% representation in ophthalmology
accounts for an average of 7.5 Black residents per year nationally or 0.06 Black residents per
year per program.
There is a conventional wisdom that URiM students are making these decisions because
they are motivated to meet the greatest needs of their communities (Chirayath, 2002; Davis &
Allison, 2013; Tang, 1995). This narrative about URiM students’ motivation conveniently
dovetails with the data about how URiM physicians are more likely to care for minority patients
in less wealthy and medically served areas (Komaromy et al., 1996). This narrative also fits with
the emphasis on the need for and the role of primary care physicians and the need to expand
access (Institute of Medicine of the National Academies of Science, 2003).
Although this is a convenient narrative, it is not empirical. Given the racialization and
hostility in other areas of medicine, it is important to also examine this distribution within the
context of other data. The distribution of URiM students runs counter to both a domestic

26
(Bennett & Phillips, 2010; Lawson & Hoban, 2003) and international (Blades et al., 2000; Jordan
et al., 2003; Scott et al., 2009; Wright et al., 2004) trend for medical students to pursue
specialization and not pursue a career in primary care. Studies find that the decision to pursue
primary care is correlated with interest in primary care (Lawson & Hoban, 2003; Wright et al.,
2004) lower income expectation (Bland et al., 1995; Gorenflo et al., 1994), less interest in
prestige (Azizzadeh et al., 2003; Bland et al., 1995; Gorenflo et al., 1994; Saha & Shipman,
2008), service/societal/altruistic orientation (Bennett & Phillips, 2010; Thomas et al., 2011;
Wright et al., 2004), and place a premium on patient relationships (Bennett & Phillips, 2010).
However, there are no significant racial/ethnic differences in interest in primary care or data to
show racial/ethnic differences in these characteristics (AAMC, 2019c).
Although it is reasonable to conceive of this distribution as students meeting the needs of
their communities, it is also reasonable to view this within the context of the hierarchy of the
specialties in medicine. The primary care fields are the least prestigious (Creed et al., 2010;
Norredam & Album, 2007) and least competitive fields (Faber et al., 2016; NRMP, 2022). The
match rates for U.S. MD applicants into the primary care fields of family medicine (98%),
internal medicine (98%), OB/GYN (84%), and pediatrics (98%), were significantly higher than
the competitive fields, including dermatology (71%), neurosurgery (74%), orthopedics (66%),
and ENT (69%). Similarly, primary care residencies, family medicine (176), internal medicine
(91), OB/GYN (3), and pediatrics (28), had a higher number of programs with unfilled slots
when compared to the competitive fields, including one dermatology, zero neurosurgery, zero
orthopedics, and one ENT (NRMP, 2022). These differences also correlate with the median
salaries, with the primary care fields—family medicine at $221,419, internal medicine at
$238,227, OB/GYN at $317,496, and pediatrics at $226,408—having the lower median salaries

27
when compared to the competitive fields, including dermatology at $462,500, neurosurgery at
$747,066, orthopedics at $568,319, and ENT at $405,503 (Faber et al., 2016).
Gaps in the Literature
Despite all of the data up to this point, there are gaps in the literature. The racial
segregation of the specialties is not well understood and not easily explained. URiM students’
career choices move against a larger trend towards specialization. They pursue lower wage fields
despite their higher rates and degree of indebtedness (AAMC, 2019a). In many ways, the racial
segregation of the specialties reflects minority experiences in selective professions. Although
they gain access to the field, they are resegregated into lower status positions within their fields
(Davis & Allison, 2013; Roberts & Mayo, 2019).
While there is a convenient explanation that does not invoke racism, the racial hostility of
medicine and the overlay of representation and salary/competitiveness/prestige makes it difficult
to ignore. While it is possible that this differentiation is due to an active choice, it is also possible
that this reflects funneling towards primary care and exclusion from others. Alternatively, this
may reflect a rational decision based on their perceptions and experiences in highly competitive
fields. As there is a growing interest in addressing representation in all fields, there is a clear
need to address this gap in the literature.
Although there has been a rise in the visibility and prominence of voices advocating for
increased diversity, there has been a rise in backlash against these initiatives. Diversity programs
have been found to activate bias and induce a backlash from non-minority members who are
upset about “preferential treatment” or “reverse discrimination” (Dyrbye et al., 2007; Milliken &
Martins, 1996). Although the Supreme Court has previously defended the consideration of race
in admissions decisions (Gurin, 2004), in 2022 the Supreme Court is considering two cases

28
challenging the continued consideration of race in admissions in both public and private
institutions (Supremecourt.gov, 2022).
Within medical education there have been notable examples of backlash against diversity
initiatives and systemic racism. In the last two years there were several examples of prominent
physicians speaking out, in the most prestigious journals, against diversity and anti-racism in
medicine. In 2020 the Journal of the American Heart Association published an article
questioning the utility, importance, benefits, and legality of diversity initiatives in cardiology
training. This paper argued that these programs lead to sub-par doctors and called for the banning
of affirmative action at the undergraduate, medical school, residency, and fellowship levels
(Wang, 2020). Similarly, the Journal of the American Medical Association (JAMA), one of the
most prestigious medical journals, published a podcast where Dr. Ed Livingston and Dr. Mitch
Katz were supposed to discuss the role of systemic racism in causing health disparities; instead,
the speakers argued that racism is illegal and therefore systemic racism cannot exist (Journal of
the American Medical Association, n.d.). Although both the Wang paper and the podcast were
retracted, it is troubling that this type of rhetoric is not only commonplace, but that the editorial
and peer review systems at the most prestigious journals are unable to identify these “flawed and
biased” studies and views (London et al., 2020). Given that these are some of the most prominent
voices in medicine, it is hard not be disheartened that these publications made it through the peer
review and editorial process.
Purpose Statement and Theoretical Framework
The purpose of this study is to uncover Black male medical students’ decision-making
process regarding specialty selection. The researcher will be employing CRT (Ladson-Billings,

29
2018; Ladson-Billings & Tate, 2018) as the theoretical framework. CRT will allow for an
analysis that accounts for the influence of race and racism in their decision-making.
In order to account for the influence of racism to create and sustain underrepresentation
in medicine, it is important to approach this inquiry from a CRT worldview. CRT starts from the
understanding that racism is ubiquitous and pervasive (Ladson-Billings, 1998, 2018). Because of
its pervasiveness, racism is built into the values and assumptions in our systems and manifest and
shape nearly all points of contact through the medical educational environment. This systemic
racism in turn acts upon minoritized individuals to create differential outcomes (Cabrera, 2019;
Ladson-Billings, 2018; Stovall, 2013).
Although there are a multitude of potential causes of ethnic underrepresentation in
medicine, there has also been a long and well documented history of explicit racism in both
clinical medicine (Skloot, 2010; Washington, 2006) and medical education (Byrd & Clayton,
2001). In medical education, there has been a history of excluding students from medical school
based on gender, ethnicity, and religion (Beck, 2004; Borst, 2002; Brown, 1996; Carlisle et al.,
1998).
CRT shifts the focus from intentional discrimination and explicit acts of racism to
investigating how supposedly race-neutral systems and structures reproduce and reinforce racism
and White supremacy (Ladson-Billings, 1998). CRT espouses the view that racist ideas are
woven into the fabric of the common narrative to justify the power and privilege (Delgado,
2012), making racism difficult to recognize and address (Delgado, 2012; King et al., 2010; King,
1991). To counter the hidden nature of systemic racism, CRT focuses the inquiry on the voices
of oppressed people to create a counter-narrative (Delgado, 1989) to uncover the, often hidden,
assumptions that systemic racism is built upon (Bronner, 2011; Ladson-Billings, 1998). This

30
counter-narrative can, in turn, stand in opposition to the dominant colorblind narrative (Ladson-
Billings, 1998; Roithmayr, 1997).
Justification
A “theory of change” refers to the researcher’s conceptualization of how their research
relates to and can drive the change they hope to bring about (Reisman & Gienapp, 2004; Tuck &
Wayne Yang, 2010). This study is built upon the theory of change that providing a counter-
narrative that centers on minoritized individuals, as defined in CRT, will not only illuminate the
URiM experience, but also identify hidden and unintentional barriers. This understanding would
create an opportunity to not only question our assumptions, but also serve as a roadmap to drive
systematic change.
The CRT framework is an ideal lens to view this problem. CRT’s success in other fields
instills confidence about its utility in academic medicine. Although CRT originated from the
field of law, it has been used to analyze racial inequities in both elementary and higher education
(Lynn, 2002; Lynn & Adams, 2002) and is now considered to be the dominant form of racial
analysis in education (Cabrera, 2019). Based on its wide acceptance in education for this type of
analysis, CRT is the most intuitive starting point for racial analysis in medical education. CRT
can help to create a wider understanding of the structure that reproduces inequity. By centering
the counter-narrative on the oppressed, it maintains focus on their lived experience in this system
and not just on their entry into the field.
CRT has the power to not only identify sources of racist inequity, but it also provides a
structure to design and communicate interventions. Because racism benefits the dominant group,
there is an inherent disincentive for leaders to participate unless there is an “interest
convergence,” where the dissolution of racist structures materially benefits the dominant group

31
(Bell, 2008). This approach is exemplified by leaders that call for diversity through the lens of
synergy by emphasizing the benefits to the individuals and the organizations (Ely & Thomas,
2016; Jayakumar, 2008; Vargas et al., 2018).
Conclusion
Although there is a growing body of literature surrounding DEI in medicine, there are
several gaps in the literature that inform this study. The existing literature often treats URiM
students and physicians as a monolithic group. However, the lack of progress in Black male
representation suggests the need to investigate racial/ethnic and gender-based differences within
URiM students and physicians. Further, there is a lack of studies investigating the causes for the
racialized distribution of physicians to the least competitive and lucrative specialties. Given the
context of racial hostility in medicine, it is possible, if not likely, that race and racism play a role
in this distribution. This study seeks to address these gaps in the literature.

32
Chapter Three: Methodology
There is a problem of racial and ethnic underrepresentation in medicine. Of the Black
male students in medical school, there is a racialized distribution of the specialties that they
pursue. Although there has been literature on how residency program directors (PD) can create
systems that address diversity, there is a paucity of literature that centers on how Black male
students select their specialty. This chapter will describe the research questions, method of
inquiry, study participants and selection that we will use to understand Black male students’
decision-making process and the influence of race and racism in that process.
Research Questions
This study is focused on the following research questions:
1. What are the critical experiences of Black male medical students in choosing a
specialty?
2. How do African American/Black male medical student resolve conflicts between
internal beliefs and external expectations with regards to specialty selection?
Overview of Design
I conducted this study using qualitative interviews of Black/African American medical
students. Interviews were semi-structured, lasting from between 60–90 minutes. Participants
were identified through both purposeful and snowball sampling. The analysis was informed by
grounded theory (Glaser & Strauss, 2004). Analysis was conducted simultaneously with the
interviews so that the results informed future interviews in concordance with the constant-
comparative method (Glaser, 1965).

33
Research Setting
In 2021, there were 94,243 medical students at 154 allopathic medical schools. The 154
medical schools include four HBCUs (Charles Drew/UCLA, Meharry, Morehouse, and Howard)
and four schools in Puerto Rico—San Juan Bautista, Ponce, Caribe, and Puerto Rico (AAMC,
2019a). Although 13% of the U.S. population is Black (U.S. Census Bureau, n.d.), only 8% of
medical students are Black or African American. Black representation in medical school ranges
from 0% to 72% with 23 schools having less than 10 Black students in their entire student body
(AAMC, 2019a). The underrepresentation is most severe for Black men, who only account for
1/3 of the Black medical students (AAMC, 2019a).
The Researcher
I am a cis-gendered Japanese male, who grew up in an upper-middle-class home and
enjoys success as an academic emergency physician. As an educated Asian male and as a
physician, I have benefited from countless unearned advantages and opportunities. As a
physician, I have been indoctrinated and professionalized in a system that rewards certain types
of abilities and achievements. My success is a testament to my ability to meet those
expectations.
In my current role, I work as an academic emergency physician at a large public inner-
city hospital that primarily serves patients who are primarily poor, uninsured, monolingual
Spanish speaking, and medically underserved. In this role, I have witnessed and cared for many
patients who have suffered from the consequences of health inequities. Within my academic role,
I have mentored multiple medical school applicants, medical students, and residents from
marginalized communities and have seen the challenges they have faced. I also spent 9 years in
residency administration for three different emergency medicine (EM) residencies. This has

34
given me first-hand experience and intimate knowledge of the standard practice, competing
priorities, practical experience, and inequities in the resident screening and selection process.
The combination of these experiences has motivated me to work to address these
inequities, especially within the realm of medical education, where I can influence meaningful
change at the local and national level. In the last seven years, my academic focus has been on
addressing issues surrounding diversity, equity, and inclusion (DEI) in medical education and
within EM residency training. In this work I have implemented multiple DEI initiatives within
my department, medical school, school board, and within national emergency medicine
societies.
Despite my interest and focus on DEI, it is important to also acknowledge that I have no
direct personal understanding of the URiM experience. Being professionalized in this system as a
non-URiM person renders many systems and biases obscure if not invisible. I also recognize that
I have an inherent disincentive to pursue this line of inquiry. Identifying the bias, racism, and
inequity within this system also means questioning the system that underpins the measurement of
my success also questions the legitimacy of my success. Identifying the flaws in the system also
means that I need to recognize and acknowledge my role in participating and perpetuating that
inequitable system. This understanding informs my decision and commitment to the use of
qualitative methods. The use of qualitative methods will clearly center the inquiry on the voices
of marginalized individuals.
As an Asian man interviewing Black men, there is a potential for mistrust and subject
reactivity. This reactivity has the potential to impact the quality and depth of the data collected.
This potential re-emphasizes the importance of good basic principles in qualitative interviewing.
Although my previous experience with mentorship and residency selection will inform my

35
interviews and analysis, it has the potential to cross over into coercion and coaching. To
minimize the influence of my preconceived notions, the interviews will be semi-structured.
Although it will be time-consuming, this will allow me time to establish trust with the subject
and to pursue responses in greater detail (Mays & Pope, 2000).
Data Sources
This study draws data from a series of in-depth semi-structured interviews. The interview
guide was developed from a review of the literature and then refined through a series of pilot
interviews. I chose a qualitative approach for a variety of reasons. In contrast to a quantitative
approach, the qualitative approach is designed to allow for the inquiry into the experiences and
understanding of the individual. CRT focus on the complex inner life of individuals that are hard
to describe and harder to quantify. Topics that are hard to quantify are better suited for
qualitative inquiry (Patton, 2002).
Additionally, the qualitative approach allows for the inquiry to be deliberately centered
on the marginalized individuals (Merriam & Tisdell, 2015). This centering aligns with CRT’s
centering on and uncovering minority voices and counter-storytelling (Delgado, 2012; Ladson-
Billings, 2018; Ladson-Billings & Tate, 2018). Additionally, although there are some existing
frameworks for understanding general decision-making, there is a gap in the medical literature
about how students select their specialty. It is therefore important to have an approach that
allows for emergent design (Creswell, 2014; Merriam & Tisdell, 2015) that grounds itself in the
experience and views of the participants (Creswell, 2014). Finally, the qualitative approach
allows for the collection of rich and thick data that will hopefully lead to additional thought and
inquiry (Creswell, 2014).

36
Participants
The participants of this study are Black male medical students in their third or fourth year
attending allopathic medical schools in the United States. Participants were identified through
purposeful sampling. Purposeful sampling is the approach where participants will be chosen for
their ability to provide information-rich cases. This approach allows for the collection of the
richest qualitative data at the expense of generalizability (Creswell, 2014; Emmel, 2013; Johnson
& Christensen, 2014). Additionally, I anticipate that the student experience is likely to be
different in HBCUs than in Historically White Colleges and Universities (HWCUs). I will be
careful to ensure that these voices are represented in sampling. Sampling was continued until
there was thematic saturation. Participants were provided with a 25-dollar gift card to
amazon.com as an incentive for participation.
Instrumentation
I employed a semi-structured approach to the interviews to allow for a greater depth of
data and a clearer centering on the Black male voices. The interview protocol was developed
through a thorough review of previous studies and informed by CRT. The interview protocol was
further refined after the conduction of three pilot interviews. The interview guide is available in
Appendix A.
Data Collection Procedures
To identify participants, I initially engaged with deans of admission, deans of diversity,
and leadership in the Student National Medical Association (SNMA) to assist with identifying
potential participants. I discussed the study and the rationale with these persons, followed by a
request to send the recruitment email (Appendix B) to potential participants in a manner that was
not only consistent with their institutional policies but maintained the greatest degree of

37
anonymity. Potential participants who responded to the recruitment email were contacted
directly.
Due to the relatively small number of Black male medical students, I also employed
snowball sampling to reach adequate sampling. Snowball sampling is the process by which
subsequent participants are recruited through the subject’s social network. This form of sampling
has the advantage of aiding in the sampling of groups that are “hidden” either because of their
small numbers or because they are part of an ostracized group (Browne, 2005; Noy, 2008). I also
directly and indirectly identified potential participants through social media. Potential
participants were directly identified through the hashtags #BlackMenInMedicine and
#Match2022. Participants assisted with recruitment through posting the recruitment email
through online affinity groups.
Interviews were conducted and recorded over the Zoom videoconferencing platform. The
use of video interviews will allow me to reach geographically disparate participants, expand the
possible times for interviews, and provide a simple means to maintain social distance. Interviews
were initially transcribed through the automated voice transcription service Otter.Ai. The
automated transcript was reviewed alongside the recording to both edit for accuracy and to de-
identify the transcripts. All files were stored on my computer in an encrypted folder.
Interviews were anticipated to last for approximately 60 minutes; however, the interviews
were continued longer when the interviewee was able to continue, and the interview continued to
uncover new data. To maximize the quality and depth of the data, I used both the interview guide
and a variety of probes to encourage the participants to clarify and elaborate their answers.
Probes were also used to ensure the accuracy of my understanding of the responses.

38
Data Analysis
Transcripts of the interviews will be imported and coded using AtlasTi (qualitative data
analysis and research software). The analysis will be informed by grounded theory (Glaser,
1967; Glaser & Strauss, 2004). Transcripts were first read through to provide a general
understanding. This was followed by a second line-by-line reading where the semantic units
were coded. Codes were created through an inductive process (Glaser, 1965). Through this
process I tracked emerging themes through memos. The codes were reviewed and combined as
necessary to avoid redundancy. Codes were further consolidated into groups. Code network
mapping was used to clarify complex themes and uncover connections between codes. Analysis
will be conducted simultaneously with the interviews so that the results can inform future
interviews in concordance with the constant-comparative method (Glaser, 1965).
Credibility and Trustworthiness
To maximize credibility and trustworthiness, all interviews were recorded to allow for
verbatim quotes in analysis. The recordings will be transcribed through the web service Otter.Ai.
Accuracy of the transcription was insured by a careful review of the transcript against the
original recordings. Although I edited the transcripts for anonymity and accuracy, to maintain the
integrity of the data, the transcripts were not altered in any other manner. To further maximize
credibility and trustworthiness, anonymized quotes were provided in the body of the paper to
allow the reader to determine their perception about my analysis.
As a solo researcher, the analysis is subject to excessive influence from my positionality.
Ideally, coding would be done by a team of researchers who would be able to serve as an internal
check to the analysis. However, this was not done due to issues of feasibility. Where appropriate,

39
I discussed the findings with trusted experts in the area to check for face validity and as an
external check on excessive bias.
To further maximize the credibility and trustworthiness, all transcripts will be included in
the analysis. To minimize the influence from my power differential, care was taken during the
recruitment and consent process to explicitly emphasize the subject’s prerogative to not answer
any question or to end the interview without any repercussions. Gift cards were provided
regardless of whether the subject did or did not decline to answer any questions or if they needed
to stop the interview. I have laid out additional precautions in the following ethics section. To
minimize the possibility of under-sampling, interviews were continued until there was thematic
saturation.
Ethics
To ensure compliance with ethical research practices, this study will undergo review and
certification by the Rossier Institutional Review Board. Because the major risk to participants is
loss of anonymity, written consent will not be obtained to minimize this risk. To ensure that
participants are aware of the purpose of the study, use of materials, risks, and benefits, they will
be provided an information sheet at the time of recruitment. Prior to the initiation of the
interview, the information sheet will be reviewed, and ample time will be made to answer any
questions regarding the information sheet.
There is a clear power differential between the researcher and the subject, thus a real
potential for coercion and violation of autonomy exists. It is possible, or even probable, that the
subject may feel obligated to answer a question they are not comfortable answering, or to answer
a question in a manner that aligns with what they may see as my expectation. Students are
professionalized in a system that places a large emphasis on authority. As an academic faculty

40
member of a major medical school and prominent emergency medicine training program, I am in
a position of clear authority within this system. Additionally, when participants were identified
by persons of authority in their medical school, there is a potential for students to feel obligated
to participate. Identifying participants through persons of authority in medical schools creates an
additional risk for loss of confidentiality.
The first step to mitigating potential coercion is investigator awareness and intentionality
during data collection. During the consent process, I will take care to emphasize that the subject
is free to not answer any questions or revoke consent at any time. I will also extend
confidentiality to include confidentiality about participation or non-participation. I will also take
care to reemphasize these points whenever there is hesitancy to respond to a question. To
additionally mitigate participants feeling that they have an obligation to participate, I will employ
snowball sampling whenever possible. To further minimize the power imbalance, I will not
recruit participants from my home institution.

41
Chapter Four: Findings
I conducted 16 interviews. All interviews were included in the analysis. These represent
ten 3
rd
year medical students and six 4
th
year medical students. These participants represent four
public medical schools, thirteen private medical schools, three HBCU/Minority Serving
Institutions, and two elite medical schools. The medical schools were in the Western United
States (6), Northeastern United States (2), South-Atlantic region (3), and the Southern United
States (4). There were no participants recruited from schools in the Midwestern United States.
Participants were pursuing residency in Anesthesiology, Emergency Medicine, General Surgery,
Pediatrics, Psychiatry, and Radiology.
Participants
For reporting the findings, pseudonyms were created for each subject. Pseudonyms were
created in an alphabetical fashion using an online list of common Black/African American
names. There is no relationship between the pseudonyms, the student’s identity, their specialty of
choice, or their institution.
Antonio is a 4th year medical student at an elite private medical school in the Northeast,
who is applying into orthopedics. He has had single-digit Black students in his medical school
class and no friends or family in medicine. One of his parents is a social worker. He attended an
elite private undergraduate university. Although interested in the highly competitive fields, he
feels a discomfort with the prestige associated with those fields.
Bradley is a 3rd year medical student currently in a research year attending an elite
private medical school in the Northeast. He has a goal of pursuing a general surgery residency
with an end goal of pursuing a highly competitive and uncommon surgical subspecialty. Self-
described as independent and self-reliant, he is also self-described as an idealist who thinks that

42
the solution is to work hard to gain recognition. He attended an elite private undergraduate
university, where he studied public policy.
Colton is a 3rd year medical student attending a private medical school in a primarily
Black city in the South-Atlantic U.S. His goal is to pursue emergency medicine as a career. He
has no family in medicine. I would like to note that this was not only the shortest interview, but
the responses were also both concrete and direct.
Donovan is a 3rd year medical student attending private medical school in the South-
Atlantic U.S. in a city with a large Black population. Planning on pursuing psychiatry, he only
has a single-digit number of Black males in his class. He entered medical school interested in
psychiatry and mental health.
Elijah is a 4th year medical student at an HBCU/minority-serving institution. Pursuing
emergency medicine, he is from a southern predominantly Black city. He is the eldest of a large
family of siblings. His mother is a nurse, but there are no physicians in the family.
Faizon is a 4th year medical student at a private medical school located in the southern
United States in a city with a large Black population. He is applying to an internal medicine
residency with the plan to enter a medical subspecialty. His father is a physician in a different
medical subspecialty and has multiple physicians in his extended family. He has a strong identity
as a person from an African country. He specifically dislikes how so much of medicine is
determined or swayed by one’s network and connections and actively rejects mentorship from
the school/faculty.
Gregory is a 3rd year medical student from a private medical school in the southern
United States in a city with a predominantly Black population. He is pursuing radiology and
attended the same university for both his undergraduate degree and his masters. Of note, he

43
stated that there are no Black radiologists at his school. His mom is a nurse, and he has an aunt
who is a dentist and another aunt who is a PA.
Herold is a 3rd year medical student attending an HBCU/minority-serving institution and
is planning on pursuing emergency medicine. Self-described as growing up in poverty in a
southern city without many public resources, he self-identifies as an independent/self-reliant
person.
Irvin is a 3rd year medical student attending a private medical school in a South-Atlantic
U.S. city with a predominantly Black population. He is planning on going into pediatrics and
entered medical school with an interest in pediatrics. He self-identifies as an independent and
self-sufficient thinker who does not blindly follow rules. A first generation immigrant from an
African country with a strong African identity, his family is very service oriented, with both
parents heavily involved in the church.
Jamyron is a 4th year medical student attending a public medical school in the western
United States and planning on pursuing anesthesia. The child of refugees, he grew up poor in a
primarily refugee community. He has no family in medicine. He attended a prestigious public
university for his undergraduate degree and had a previous career in business/banking.
Kaydron is a 3rd year medical student at an HBCU/minority serving institution. He is
planning on pursuing a general surgery residency and/or a combined general surgery/surgical
subspecialty program. His mother is a lawyer, but has no immediate family in medicine. A first
generation immigrant, he has a strong identity as a person from an African country.
Latrelle is a 3rd year medical student at an HBCU/minority serving institution in a
primarily Black city and is from a primarily Black southern city. He is planning on entering
anesthesia. He has been well supported by family, but his father was unsupportive of him even

44
going to college. During a gap-year, he worked at an orthopedic surgery center, where he both
solidified his perception of orthopedics and was introduced to the field of anesthesia.
Markael is a 4th year student attending a public medical school in the western United
States. He has matched into a general surgery residency. He struggled academically during his
undergraduate career. He had a previous career in the military. His mother is a nurse, and he
described how he grew up in a family that was focused on service. He is a first generation
immigrant with a strong identity as a person from an African country.
Narquise is a 4th year medical student attending a private medical school in the western
United States. He applied to and did not match into a highly competitive specialty. He is
planning on reapplying into radiology. Married with a previous career in politics, he was born
and raised outside of the United States.
Olin is a 3rd year medical student attending a public medical school in the western
United States. He is planning on entering general surgery with the plan to pursue a fellowship in
trauma/critical care. He is from a mixed White/Black family and played collegiate football. His
mother is a physician and he grew up in a primarily White community.
Pernell is a 3rd year medical student attending a private medical school in the western
United States. He is planning on entering orthopedics, but in his undergraduate years, he was
initially pursuing a career in engineering. He grew up in a religious family that was focused on
service.
Where appropriate, direct quotes have been edited for grammar and readability and to
protect subject privacy only. Care was taken to not change the content or the tone of direct
quotations. Edits for privacy were noted in brackets. No notations were made for changes for
grammar and readability.

45
Research Question 1
In Research Question 1 (what are the critical experiences of Black male medical students
in choosing a specialty?), participants described a complicated process of identifying interests
and exploring fields. They identified their priorities and weighed them against the merits of each
field. However, their experiences and decision-making were shaded by racialization. They
experienced racialized expectations about the fields they would enter and various degrees of
racial hostility in those fields. Not only did these experiences increase the complexity of their
decision making, but they also created an internal conflict between their personal interests and a
sense of racial obligation. Despite this, all participants were able to reconcile these conflicts and
identify the field that met their needs and priorities.
Medical School Guidance for Specialty Selection
Participants described specialty selection as a complex and difficult process with
logistical barriers to fully exploring all their potential interests. Although this is a critical
decision, participants described the medical school administration’s guidance to be largely
hands-off in guiding participants through the process of identifying their specialty of interest.
Antonio states “there was no sort of like, mentorship and like, this is like, what you how you
should think about this … no one really sat down and said, Hey, this is what you should be
thinking about this is you should be thinking.” Subjects described how when their schools did
provide guidance, the predominant message was “they always push us choose something that
you think you would enjoy that you could see, like … enjoying that day to day (Donovan).”
Some institutions refined the message of “do what you like” with the guidance that “go to where
you feel you can fit in with the people … where you like, kind of the mindset that the people
have (Irvin). ”

46
Subjects described how their medical schools appeared to function on an expectation that
the participants will figure it out during the clinical rotations of the third year and hopefully have
a proverbial “aha” moment of clarity. Herold theorized the medical school’s rationale for taking
this approach.
It was not a clear message. They're definitely there to help you for sure … they're coming
with this mentality that, you know, we have direction and … a purpose, and we can attain
that and if we need a little bit of nudging and pushing that we can do that, but I guess it's
supposed to be they feel like it's all within ourselves or that we will find a way.
Although all the subjects were able to identify the specialty they were going to pursue,
there was a general sentiment of dissatisfaction with the degree and the quality of guidance from
the medical school administration. Antonio, Donovan, Faizon, Kaydron, and Latrelle specifically
described their medical schools’ guidance to be insufficient. Colton described how he relied on
upper year students to identify and sort through his interests. No participants described their
medical school’s guidance to be sufficient.
Exploration Through Clinical Experience
All participants discussed the central importance of their direct clinical experiences in
shaping their specialty choice. For some participants it was where they were able to identify the
field of interest. Even for subjects who entered the clinical years with an interest in a specific
field, it was an opportunity to affirm their choices. Clinical rotations were the first time that
participants were able to participate in a clinical care team and gain a practical understanding of
the field.
Participants described clinical rotations as the first time they were able to both act as a
part of a clinical care team and gain a practical understanding of the specialty. Rotations were

47
described as an opportunity for both self-discovery and growth. Participants found that clinical
rotations were full of positive and negative surprises, where preconceptions were both confirmed
and refuted. Gregory recalls his orthopedic rotation, “So initially, I wanted to do orthopedic
surgery, but I realized I didn’t like the operating room.” Similarly, Markael described his
experience on pediatrics.
There were several specialties that really caught me off guard that I didn’t realize I would
enjoy. For example, pediatrics, I just didn’t think kids would like, like me or something.
And it was amazing. I loved working with kids. Pediatrics was one of the specialties
where I was like, wow, I have to actually think about this versus surgery.
Participants described how these experiences helped them to refine their interests and to identify
their priorities in their specialty selection.
Participants often repeated the importance of being able to project themselves into the
future within this field. Participants are often excited by the novelty of many aspects of clinical
medicine. Projecting themselves into the future tempers excitement and to think about the field
more holistically. Antonio stated:
Psych ... when I was on clerkships, I really liked. I liked the patients that you were
working with, in the context of it … I was like, well, this be okay, in 20 years. Will this
really be, is this what I want to do for the rest of my life is listen to the people like this. I
was like, no, not really.
Projecting themselves into the future was also a way that participants considered their personal
priorities against the professional requirements. This consideration was raised in several
discussions about alignment between the lifestyle of the field and their personal priorities.
Narquise commented:

48
Okay. And I could see myself maybe doing it, but I’m in my, like, I’m 33 going to 34 this
year, and I don’t want to be in my late 30s, think about having a kid and like working for
many years for six[ty] to eight[y] hours a week. And especially when I could see myself
happy without being a surgeon.
Despite the importance of these experiences, there was considerable institutional
variability of participant’s access to both clinical experiences and mentorship within their field of
interest. While Bradley, who attends an elite medical school, has a department in his highly
competitive and uncommon surgical subspecialty, Kaydron, who attends a HBCU/MSI, has no
physicians practicing in the surgical specialty of interest. Similarly, Latrelle, who also attends a
HBCU/MSI, does not have a department of anesthesia.
Racialized Expectations and Black Racial Obligation in Medicine
In addition to their internal struggle with specialty selection, participants described a
variety of racialized experiences and pressures that influences their decision-making. These were
described as a variety of both subtle and explicit messaging that reflect assumptions and
stereotypes about Black men’s interests, priorities, and motivations. Although the messaging is
subtle, its ubiquity creates a sense of racial duty that creates a barrier to participants deciding
based on their personal interests and priorities.
Subtle Push Towards Primary Care
Although the official messaging from medical schools is that all students should pick
what they are interested in, participants described how they felt that their choices were restricted
by racialized expectations. Fourteen of the 16 participants expressed their belief that Black men
were expected to pursue primary care. This expectation was seen as coming from both official
messaging from the medical school administration as well as from individual interactions with

49
patients, peers, residents, and faculty. Although the messages were “almost never explicit. It’s
almost always subtle (Jamyron),” they were experienced as coming together to create a “societal
perception would be that [Black students] would be going into primary care (Colton).”
Although the messaging was subtle, this expectation was described as palpable and
ubiquitous. This message was seen as being repeated, reinforced, and solidified through multiple
avenues. It was seen as being expressed through peer, resident, and faculty assumptions about
their interests and motivations. Olin reached out to the Department of Surgery because of his
interest in surgery but got the response, “When I showed them my CV, they’re like, yeah, this is
pretty good for someone who wants to go into family medicine.”
Participants described how this message was often an outgrowth of the framing of racial
health disparities. Medical school administration and faculty were described as framing the
issues of racial health disparities and physician underrepresentation as linked. Discussions about
racial disparities in both access and quality of care were paired with discussions about the
advantages of racially congruent care. This framing placed physician diversity as a central
solution to racial health disparities. Colton stated:
I think that one thing that’s been big in medicine is sort of in terms of patient care,
you know, people wanting to be taken care of, by a provider that looks like them.
And so with that, when there’s more people of color are going into medicine, then
I feel like the societal perception would be that they would be going into a
primary care.
Additionally, the discussion around racial health disparities was described as centering around
primary care. The discussions centered around the primary care shortage and the potential role
for primary care physicians to directly address these disparities.

50
This framing was described as having the effect of emphasizing both participants and
other underrepresented in medicine (URiM) students’ role in addressing health disparities. At the
same time, it was seen as narrowly defining the way they were expected to contribute. This had
the effect of creating a sense of racial obligation that not only pulled participants towards
primary care, but also pushed them away from the non-primary care fields. Olin related:
It’s kind of hard to parse out to be honest … I think the times in which I really noticed it,
is when people would say, like, primary care is really important, especially for your
class … the most diverse class in [our school’s] history … whether it was speeches or
lectures or things like that from people [outside of the DEI administration]. … There’s a
lot of you know, this most diverse class … is one of the most well equipped to solve
the … the problems, our communities of color face.
Service-Diversity Connection and the Push Towards Primary Care
Participants additionally identified that the push towards primary care was an outgrowth
of a service-diversity connection. Many of the subjects specifically identified service as one of
their main motivations to pursue medicine and an important consideration in their choice of
specialty. However, participants also described an external expectation that they were primarily
motivated by their desire to provide service to the Black community. Gregory described this as
“there’s that hand waving on, you know, like, you’re supposed to go back and help your
community.” Gregory goes on to question as to whether this expectation is unique to Black men
in medicine or if it is seen in other professional fields as well.
I mean, for my friends who are in business and engineering don’t really know if they get
that kind of same perception that they need to go back to their community and like, do a

51
specific thing to help, as opposed to just being out and about doing their thing and being a
young professional.
Assumptions about participants’ motivations were seen as dovetailing with the dominant
definition of service to further push participants towards primary care. As described earlier, the
framing of health disparities emphasized the importance of primary care and a deemphasis on the
other non-primary care fields. As an extension, service was seen as the exclusive domain of
primary care. Olin commented:
I feel like, I’m caught. Like, I feel like a lot of my me and my classmates are pressured a
lot to go into primary care, because it’s the fact of the matter is, is like you will make a
bigger impact per person. Or like in the community, like overall, as a primary care
physician … the things that are killing us are things that just need resources and attention
and like a good primary care provider that they will listen.
The multitude of messages were seen as coming together to create a sense of racial duty
or obligation. Olin states, “Like, there was never any individual said like, you should go into
primary care because you’re Black. I think it was more of like, there was just like this general
theme of ... this is why you’re here.” Participants who were interested in non-primary care fields
described feeling conflicted about their career choices. They described a feeling of having to
choose between their desire to give back to the Black community and pursuing their interests.
Jamyron explained:
This dilemma within myself of whether choosing something like anesthesiology was …
based on like, remarks … [it] was like a cop out ... “You know, like you explicitly talked
and we’re very passionate about giving back to your community …” in discussing this
with people that I was more inclined to be almost defending my decision, versus like,

52
stating what I wanted to go into, which I thought was very interesting, and most likely
very unique to minorities,
Community and Black Patients’ Expectations
The most explicit push towards primary care came from Black patients and members of
the participants’ community. Gregory recalls “when I [tell Black patients] I’m interested in
radiology … one or two times someone said, oh, you should be like, a primary care doctor, like
come work at this clinic so, you can take care of me later.” Donovan echoes this experience,
“I’ve gotten this from a few patients … psych is good, and all that, like [but] family medicine is
so much more important. We need more doctors like you.” Latrelle recalls hearing the same
message from members of the community: “You tell people… I’m trying to get into medical
school, the first thing that they say is, oh, yeah, go off, become that doc, and then come back and
take care of me … I’ve heard that hundreds of times.”
Although many of these messages were made casually and did not make a substantial
impact on the participant’s decision-making, there were examples where they carried substantial
weight. Irvin recalled a patient interaction he had on his pediatrics rotation.
[My Black patients] they’re like, they’re like, super, they’re like, you know, I’ve never
had a Black pediatrician or a Black male pediatrician … I literally had one time a [Black]
patient [in the pediatrics clinic], … Yeah, well, you know, I really, like love this, and I
want to go into pediatrics. And she literally got up and like, gave me a hug and I started
crying. And yeah, it’s been resounding, like, just really grateful … And yeah, it’s ... just
like heavy or just like, how much people are … just rely on me just really the difference
that I can make in these people’s lives?

53
Participants acknowledged the positive intent of these messages as well as the expression of the
speaker’s perceived needs. However, these messages had the effect of contributing to the sense
of racial duty.
Elite Medical Schools
While most of the participants described how they were pushed towards primary care,
subjects from elite medical schools were the exception. Antonio and Bradley were the only
participants to not express the belief that Black men were expected to pursue primary care. They
instead expressed their perception that Black men are expected to pursue competitive fields such
as orthopedics, ophthalmology, and neurosurgery.
The elite medical schools were also described as having a tangible anti-primary care bias.
Antonio recalls:
One girl voices [that] she wanted to do family medicine. And [the professor] was like,
“you don't come to school like this to do family medicine, you come into school to be
plugged into, like tertiary care and to do research,” which I still think it’s true.
The specialty focus was seen throughout the medical school career, including in the prominence
of specialty student groups and the opportunities for clinical exposure. While many schools
lacked clinical opportunities in highly competitive fields, these institutions lacked many of the
clinical primary care opportunities that exist at other institutions.
Primary Care Within the Hierarchy of the Fields
Despite medical schools’ messaging about the importance and value of primary care,
participants described commonly receiving negative messaging about the primary care fields.
Residents in non-primary care fields commonly discouraged participants from pursuing primary
care fields. These messages centered around a refrain of “it’s not worth it (Donovan)” and

54
emphasized the lack of prestige and pay. Although this negative view was most pronounced at
the elite medical schools, the negative view of primary care was also seen at the HBCU/minority
serving institutions. Kaydron talks about how residents from multiple fields discouraged him
from pursuing primary care.
People like discouraged me from like, going into primary care despite coming from a
primary care school … So, I mean, like, emphasizing like, the amount of work
emphasizing like the prestige versus like the pay … So, like, I feel like the school …
[was] emphasizing primary care, some other people were … deemphasizing primary care
from more of like, a prestige point of view, or, like a pay point of view.
Participants also expressed similar beliefs about primary care. Participants described their
expectation that high performing students should pursue competitive fields. “I [had a very high
score on standardized testing]. So now I'm going to do something that I could actually use a
much better QOL and it was a quality of life, as opposed to anything in primary care (Antonio).”
While there was a recognition of the need for primary care physicians, other subjects similarly
reflect a negative view about the prestige and desirability of primary care. “I’ve always had to
say, like, primary care is, you know, low balling it … I’m not going to settle for less (Latrelle).”
Racial Stereotypes and the Push Towards Orthopedics
Like primary care, orthopedics stood out as a field with a strong association with Black
men. Although multiple participants expressed their belief that Black men were not expected to
pursue the most competitive fields, many felt drawn to the field. Antonio, Colton, Elijah,
Gregory, Jamyron, Kaydron, Olin, and Pernell all expressed an initial interest in orthopedics. In
comparison, only Elijah expressed an initial interest in primary care.

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Participants identified several reasons for the appeal of orthopedics. These reasons
primarily centered on the alignment between orthopedics, sports, and their self-identity as
athletes. Both the field of orthopedics and orthopedists have a close association with sports and
athleticism. “[T]here definitely is the ortho like stereotype. You know, the like, gym bro type
stereotype and I have been told because I do like to work out and try to stay in shape (Pernell).”
“Yeah. So, coming into medical school, I was full on orthopedic surgery, because of like the
anatomy and the sports aspect (Gregory).” Participants identified a similar thought process
among their peer group. “... a good chunk of Black males want to do ortho, because they see
sports, they resonate with sports, and they put two and two together. So they’re like, why not
(Elijah)?”
Participants also described an external pressure to pursue orthopedics. Like the push
towards primary care, this push was seen as coming from people’s assumptions about their
expectations and assumptions about their interests. In contrast to the push towards primary care,
these messages came from casual conversation and not from official sources such as medical
school administration. Like the internal motivations, external expectations were seen as an
outgrowth of the association between orthopedics and sports. This external expectation was seen
as not only common but also ubiquitous. Jamyron talked about how this expectation was so
commonplace that he started to question the reason for his interest in orthopedics.
Early on that people automatically gravitate towards like Black male, athletic, orthopedic
surgeon. I also kind of like, got that vibe. And it seemed like, I wasn't 100% sure if it was
something that I was interested in, or it was just something that kept gravitating towards
me, or people kept pushing me towards like, oh, yeah, you you played sports, you’re
athletic, you should, like a lot of athletes go into orthopedic surgeon.

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Although participants provided examples of the external assumptions being based on
first-hand knowledge about the participant’s background, they also described examples where
they were based on their outward appearance. Participants had a variety of responses. Kaydron
saw this as a reasonable assumption based on physical stature.
It depends a lot of the things or a lot of the stereotypes that also depends on the physical
attributes of the bloodline. So, I mean, like, if you’re like, six, five, like 230, everyone’s
going to think you want to do you want to do ortho or if you want to do sports, you want
to do sports medicine.
In contrast, Pernell described his discomfort with these assumptions. Pernell recognized the
intersection of the stereotype of Black athleticism and the expected interest in orthopedics. He
identified the racialized nature of this assumption and described his struggle with attributional
uncertainty.
You know, from people when I say, oh, I’m interested in orthopedics. I’ve heard oh, you
look like you would go into ortho. You know, and that could mean a lot of different
things. It could mean from athletics. I don’t know if that was racially based, like, I don’t
know. But I’ve heard, I’ve heard that several times.
Internalized Beliefs About Representation and Underrepresentation
When participants were asked what fields, they expected Black men to enter, there was a
consistent belief that they were expected to enter primary care. Herold responded, “without
digging too hard into it, with what automatically popped in my mind was family medicine or
psychiatry.” Colton, Elijah, Faizon, Gregory, Jamyron, Kaydron, Latrelle, Markael, Narquise,
Olin, and Pernell all expressed the same expectation that Black men were expected to pursue
primary care.

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At the same time, there was a notable paucity of participants who believed that Black
men were expected to enter the most competitive fields. Of the sixteen interviews, only Antonio
(cardiology, orthopedics, neurosurgery) and Bradley (plastic surgery, orthopedics, urology)
expected Black men to only go into the highly competitive specialties. Additionally, Kaydron
also expressed his belief that Black men were expected to pursue orthopedics but also expressed
an expectation that they would pursue primary care. To underscore the lack of participants that
expected Black men to pursue a career in a highly competitive specialty, Faizon responded that
his expectations were “not things like ophthalmology, not things like urology, not super
specialized fields, I can say that, but I can’t say like internal medicine or family medicine, just
not like super subspecialized fields.”
Participants identified representation within the individual fields as a major influence in
their beliefs. Participants expected Black men to pursue fields where they saw a high degree of
representation and not when there was low representation. Markael described his expectations
for specialties for Black men “so surgery, and then obviously, its subspecialties … you know, I
just didn’t see that many .… Any of the subspecialties be honest, I just felt like I naturally before
I even saw the numbers naturally assume that most Blacks went into primary care.” The effect of
representation was seen in fields where there are low levels of national representation. Both
Antonio and Bradley expressed how representation among their peer group shaped their
perceptions.
When I came to med school, I assumed every Black guy that I met was like going into
like, ortho or like plastics or something because they were very, like, I was just like,
these, they’re so like, focused, that I was just like, wow, these guys are on a mission ….

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But you know, like, have a few in my class like, you know, urology, like some kind of
surgery some kind of like, lucrative surgical specialty….
Participants provided a variety of internal and external explanations for
underrepresentation. Participants identified a variety of environmental and systematic barriers to
the pursuit of the competitive fields. These included issues such as access to mentorship and
development opportunities (Antonio, Bradley, Faizon, Gregory, Narquise) and racially hostile
environments (Faizon, Gregory, Jamyron).
A minority of participants attributed the underrepresentation to negative beliefs about
Black male motivation and ability. Markael discussed how he intellectually understood the
effects of systemic racism, but struggled against attributing underrepresentation to Black male
deficits.
I think in surgery, or in any field, if there’s a bias already, based on race or anything like
that, it’s further exacerbated if there’s a quote/unquote so-called skill involved … there’s
a subconscious belief that well, Black, fewer Blacks are in the specialty because fewer of
them have the skill for it.
Although Markael describes his struggle against internalizing beliefs about Black deficit, he later
describes additional beliefs about Black deficit. He expresses his belief that the cause of
differential expectation comes from Black men’s inability to score well on quantitative portions
of their application.
I think it stems from two possible subconscious beliefs, maybe about ability to score well,
thinking that score means clinical skill, as well .… So, that’s where, like, I guess, IQ and
all of that this smartness factor [is valued in surgery], and then diversity is more of like,
IM (internal medicine). IM and FM (family medicine), if you will.

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While Markael described his beliefs about Black male deficits in an oblique manner,
Elijah and Latrelle were more direct about their beliefs. Elijah attributes overall Black
underrepresentation in medicine as an unwillingness to engage in delayed gratification.
It’s unfortunate that you know, because coming from [poverty in a city in the United
States South] that’s the biggest thing, like, if you see individuals trying to make it out,
they’re trying to make it out via do sports, or rapping or things like that. But the niches of
like just going to school delayed gratification, that’s not really a thing .…
Latrelle echoes this belief in his thoughts about the competitive specialties. He attributes the
underrepresentation to a lack of motivation among Black men.
[I don’t expect Black men to pursue] dermatology. Just, you don’t hear Black, Black men
talk. Black men don’t want to put in the effort. And I know whatever it goes into
becoming a dermatologist. Personal history with you know, low balling expectations. In
just historically, Black people in general, especially Black men, they don’t they’re not
pushed to go the extra mile to go into dermatology or the orthopedics like that .…
Racial Reality in the Clinical Space
Participants described a wide range of both positive and negative experiences and
impressions of the various fields. While many of these experiences were described as stemming
from their interest or lack of interest in the subjects, many of their impressions were specific to
their identity as Black men. These experiences were described as reflecting a racial reality of
differential treatment, expectations, and evaluations. These differential experiences, in turn,
shaped their perception of the individual fields as being welcoming or hostile to Black men.

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Welcoming and Unwelcoming to Black Men
Fields were described as having a broadly welcoming or unwelcoming clinical
environment. Fields such as pediatrics and internal medicine were seen as welcoming while
surgical fields were seen as less welcoming. Participants saw these environments as being natural
extensions of the required skills in that field. In fields such as pediatrics and psychiatry, being
able to connect to the patient and make them feel comfortable is a necessary skill, while clarity
and directness is needed in the surgical fields.
Each field was also seen as having a specific disposition towards medical students and
their education. Bradley described how he felt welcome on his internal medicine rotation because
they placed learning and education at the center of the clinical experience. The most welcoming
fields typically did their best to incorporate the students into clinical care, as opposed to having
them in the role as passive observers.
Beyond the general impression of the clinical and educational environment, participants
described the fields as being specifically welcoming or unwelcoming to them as Black men.
Racially hostile fields were described as emphasizing conformity, hostile to their identity and
perspective, and had an unfair system of evaluation. Fields that were seen as racially welcoming
not only valued their perspective, but encouraged them to bring their entire selves to the clinical
environment. Psychiatry, internal medicine, and anesthesia were seen as specifically racially
welcoming while OB/GYN and orthopedics were seen as specifically racially hostile.
Psychiatry and Tangibly Valuing the Black Perspective
Psychiatry was a field that multiple participants identified as being specifically
welcoming to Black men. Despite their various interests, Antonio, Bradley, Donovan, Herold,
Kaydron, Latrelle, and Pernell all spoke about their positive impressions of psychiatry.

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Collectively, they described a tangible racial awareness that informed the clinical practice as well
as their approach to medical students.
Psychiatry was described as a field that clearly identified and discussed the intersection
of race, racism, and health. They identified the unmet needs within Black communities and
worked to address them. At the same time there was a self-awareness about how it is viewed by
Black patients and how that presented a barrier to care. Latrelle stated:
Just the push within the Black community that mental health is real in this community,
like people kind of turn a blind eye to it. Like it’s not real. It’s something that we don’t
talk about … the last year or two like they’ve been pushing, you know, psychiatry.
Within the context of this racial awareness, psychiatry was also seen as a field that not
only spoke about the value of diversity, but tangibly valued both diverse perspectives and
racially concordant care. Participants described how they felt that they were not only valued as
members of the care team, but the team also valued them for their perspective. Within this
environment, they felt encouraged to bring their entire selves to the clinical work. Kaydron
commented:
Um, I would say that psychiatry … at least acknowledged, acknowledged, like, race and
acknowledged, like, the importance of like, like race or the importance of like, having
providers that look like, like the patient … just also just feeling just like how I how I felt,
my opinions or my presence was, was accepted ... I felt like my opinion or my
perspective was valued more in that rotation.
Kaydron goes on to describe how this sentiment was reinforced by the positive responses from
his Black patients.

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Internal Medicine and Racial Awareness of the Student Experience
Participants identified internal medicine as also being specifically welcoming to Black
men. Like psychiatry, internal medicine was seen as having a high degree of racial awareness in
both clinical care and the educational environment. Participants identified internal medicine as
having an especially keen awareness of the differential experience of Black students on their
service.
Faizon described how on his internal medicine rotation, instead of assuming that Black
students were comfortable, the care team actively worked in a manner that he described as “what
can we do to make you feel welcome here?” Participants described how faculty not only had an
awareness of the possibility of a differential experience of Black students, but they also took an
active role in ensuring an equitable experience. Pernell recalled two especially racially aware
internal medicine attendings.
There’s also been situations, you know, where patient like, we were in a room in rounds,
and I’m the only Black person on the team. And, you know, the patient singled me out
and like, was like, hey, proud of you, brother … my attending came to check in with me,
because he was like, hey, like, I noticed this, like, are you okay with that? I just want to
make sure … at the VA hospital, ... [I] had multiple of these racial events happen … this
white elderly male patient, um, who kind of picks me out again, I’m the one Black person
in the room. And he just goes, “Hey, we’re, where are you from?” And I was like, “Ah, I
was born in LA, but my parents are from Ghana …” I can’t remember the story … he
helped some guy from Ghana … we came out of the room. And the attending (different
attending) immediately came up to me … to make sure like, everything’s okay.

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Pernell described how these attendings were attuned to him being singled out for being Black.
They were also proactive about addressing it and engaging in racially aware conversations.
Pernell goes on to describe how he appreciated that these issues were addressed in a manner that
did not make presumptions about his experience and that they asked him what he felt was the
most appropriate way to address these incidents.
Racially and Gendered Hostility: OB/GYN and Orthopedics
OB/GYN and orthopedics were identified as fields that were specifically hostile to Black
men. These were described as fields with specific and rigid environments that emphasized
conformity over diversity. These fields were also described as having environments with norms
that were not only foreign to Black men, but were experienced as being specifically hostile.
Orthopedics. The experience of orthopedics provides an interesting contradiction. As
mentioned previously, many of the participants described both a pull and an external push
towards orthopedics. Despite this expectation and interest, orthopedics was often experienced as
specifically hostile to Black men.
Participants universally identified orthopedics as a highly competitive, prestigious, and
lucrative field. Participants were not only aware that applicants to orthopedics need both high
standardized test scores and extra-curricular activities to be competitive, leading to some
participants to self-select against pursuing orthopedics. “I don’t have like the step score, [and]
research yet for orthopedics. So that’s why it’s kind of lower on the list (Gregory).” As a highly
competitive field, orthopedics is by its nature exclusive; however, this was described as
extending into being exclusionary and unwelcoming. “I think orthopedic surgery is its own beast
as well. But that is just exclusionary to its own. It’s its own thing. Yeah. (Faizon).”

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Orthopedics was also described as being dominated by White males and centering on the
White male perspective. Participants describe an environment with expectations surrounding
formality, diction, and deference that contributed to its hostility. Latrelle stated:
[Orthopedics] was very uncomfortable, I felt like I couldn’t be myself or express myself
or talk the way I wanted to, because for a long time there and it was I was the only
person, Black person, Black man working there, it’s such a male ... white male dominated
field.
Participants describe how although the expectations and norms were both unstated and
unwritten, they were expected to be familiar with the expectations. Participants describe how
mastery of the material and clinical ability were insufficient and that they were judged by the
way they communicated. Antonio commented:
There’s like probably three surgeons in ortho world who come to mind who were all like,
older white men. It was like, I wasn’t presenting information to them in the way they
wanted it to be presented. And like, even if I did the right thing, even though I was trying
to do the right thing, it just wasn’t seen in the right light. Now, that could be because I
was a Black male, maybe it could because they didn’t like me, it could be some
combination of the both.
Orthopedics was not only seen as centering on the White male perspective, but it was also
seen as centering on a specific type of White male. The culture of orthopedics was seen more
akin to a “jock” or “frat” culture in contrast to the “nerd” culture of a field like internal medicine.
Herold nnoted:
We had an orthopedic resident on, so his friends used to come in and used to see kind of
how they socialized … the most orthopedic surgeon, residents that I’ve seen, and this was

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mostly at [hospital] was the kind of very tall white males mostly … I definitely had got
that frat, fraternity vibe from orthopedic surgeons. And I wasn’t in a frat at college …
definitely not interested in white fraternities.
This jock/frat culture was also described as analogous to a locker room environment. This is an
environment where the conversation had an underlying thread of racism and sexism. Within that
environment, any objection would be dismissed because this was just “locker room talk.” Olin
stated:
It just felt like I was in the locker room again, like there was a lot of the way people
interacted how people talked about things, what people talked about opinions, people had
values people held … But there is kind of a through line of just like a hint of a little bit of
misogyny just like a sprinkle of racism here and there just like very like casual, like I’m
saying these things to sound entertaining to the people that I think would find this
entertaining type of type of stuff. And to be honest, that was what kind of my least
favorite part of football.
It is important to note that participants’ experiences and perceptions of orthopedics were
not uniform. Both Antonio and Pernell, who are pursuing orthopedics, described positive
experiences and impressions of orthopedics as a field. Antonio described how the orthopedists
were welcoming and encouraging when he reached out in his pre-clinical years; however, he
described multiple racially based barriers and hostilities during his clinical experience. Pernell’s
experiences stand out as the single participant with a universally positive impression of
orthopedics. Pernell not only described how he found a White male mentor in orthopedics who
was welcoming and encouraging, he describes his clinical experience, “I did orthopedics and I
really enjoyed it I loved, you know, all the procedures, I loved all the people and just the patient

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population you worked with.” Unfortunately, there were no participants from the same institution
who were able to either corroborate or refute these impressions.
OB/GYN. The environment of OB/GYN was described by participants as being
generally hostile and exclusionary. Antonio, Bradley, Faizon, Herold, Irvin, Latrelle, Markael,
Narquise, and Pernell specifically identified OB/GYN as being specifically hostile. There were
no examples of participants describing OB/GYN as welcoming. Participants described a general
feeling of exclusion that was alternatively attributed to a combination of their role as medical
students, their gender, and their race. Narquise recalls,“OBGYN actually really liked … but I
didn't feel I also didn’t feel accepted … it felt like would be a lot of work to make myself
accepted and included.”
There were multiple aspects of this negative impression that made OB/GYN stand out. In
contrast to other rotations where exclusion and hostility was below the surface, OB/GYN was
unique in that exclusion was generally more overt and in multiple incidents escalated to overt
conflicts. “Like, people had, like, literally explicitly been like, “You’re a man. So, like, you
shouldn’t be here.” Like, like, literally that. And I was like, cool. I have to be to graduate
(Irvin).” OB/GYN was also unique in that participants specifically identified both nurses and
patients as a source of hostility in addition to the residents and faculty. Faizon commented:
I don’t think that my identity gave me any specific problems like in any of the six
rotations that I had to do. The only one would possibly be obstetrics and gynecology … I
can’t speak to like a patient asking for me to not be in the room. I can’t, like untangle that
from me being a male versus me being a Black male … other than that, like, there are
there are ways that like nurses and things would speak to me.

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Despite the widespread negative impression of the field, participants described
attributional uncertainty for their exclusion. Bradley describes how students were treated like an
inconvenience:
There’s some services where … students are just generally like a little less welcome,
because they’re like a genuine inconvenience. And I can appreciate that. It’s like, you
come on OB GYN sometimes, like it’s just very hard to take your student around, like, do
that.
Participants also understood the need for male students to be excluded from certain portions of
patient care. “So, the only time I got asked to leave the room a couple of times for pelvic exams
in OB GYN, but I feel like that was fully within reason (Faizon).” However, when their
exclusion was excessive or different from other students, participants were left to wonder about
the relative contribution of gender and racial animosity. Antonio said:
In the context of seeing, like relative treatment compared to other people and other
people’s experiences … certain attendings were it was like, very odd … like, what is in
your craw with me like, like this, this, this is not how you should be treating a medical
student. And I can’t tell if it’s just you really hate medical students, you don’t like Black
men or combination of both?
Despite the attributional ambiguity, participants identified OB/GYN as being specifically
hostile to Black men. Participants described several features that lead to this hostility. Like
orthopedics, OB/GYN was described as having rigid expectations and unwritten rules that
centered on White female norms and perspective. OB/GYNs were seen as being primed to
perceive threats and quick to judge. Despite their judgment, OB/GYNs were seen as unwilling to

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provide corrective feedback, resulting in a space where participants were not able to perform.
Irvin commented:
I would call the culture OBGYN to be what I call White woman culture. And essentially,
it’s like, things need to be done in this very particular way or wrong. And if I have a
problem with you, I can’t tell you I need to go through some like weird little yellow brick
road thing, right? ... they grade the students is, they put like, your face on the wall. And
then everyone like, talks about you and like, makes jokes and stuff … it was just like this,
like, very, like smile in your face. But like, talk sh*t behind your back.
This environment was conducive to overt conflict and hostility. Markael described a
conflict that resulted from him asking what he thought was an innocent question. His perception
was that the resident was primed to perceive threat and was quick to perceive his question as an
attack.
[I had] a patient who had an ectopic pregnancy, was asking if the egg could be moved …
And so the resident came in and was like really angry and upset about that … I think I
brought up like, maybe in the future, that could be a possibility … I had read recently
about ectopic transplantation where you move a limb somewhere else … And she went
off on me, like, just completely went off on me. And later, we found out it was more
about the Republican argument … that pretty much soured our relationship after that.
Markael goes on to describe how this animosity persisted throughout the remainder of his
rotation, despite his attempts to make amends.
Participants described being caught in a no-win situation. As described earlier,
participants were excluded from various types of clinical care and generally made to feel
unwelcome. When the participants engaged with the residents, they risked hostility. At the same

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time, the residents who were excluding the participants, criticized them for being disengaged and
disinterested. Irvin stated:
[My resident said] “You’re unprofessional. And you seem not interested in kind of the
work of being here … you’re in trouble for not going in to see a C-section to assist” … a
C-section that the surgeon had told me not to go to. So, make that make sense. And yeah,
it was just like, every day, I was just like, “This is stupid. I’m not wanted here … like, let
me just try to learn.
Participants attributed this hostility to a variety of sources. Some participants saw this
hostility as an outgrowth of both gendered and racially based conflicts. Faizon saw the hostility
as an outgrowth of sexism within medicine. “The entire field of obstetrics and gynecology is
oriented around a chip on your shoulder for being female and just not being taken seriously in
the field of medicine historically.” In contrast, Irvin saw this conflict as an extension of societal
conflict between White female and Black males.
No, cuz it’s, it’s, I mean, if you want to just take out of the medical just in historical lens,
like, that’s, that’s kind of the dynamic, right? It’s like, White women versus Black men,
like, if you want to kind of look at the, you know, that that’s this, how it’s been. And so
why would it change in a professional setting?
Regardless of the attribution, there was consistency among participants’ perceptions of this space
as hostile.
Mentorship and Guidance
Given the lack of guidance from the medical school, mentors played an especially
important role in many participants’ specialty selection. Participants described a wide range of
mentors who varied across multiple characteristics. These included personal characteristics such

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as race, gender, ethnicity, position, specialty, and age. They varied in their proximity, with
several coming from outside institutions. They varied in how they connected, participants
described both mentor and mentee-initiated relationships as well as those that grew from formal
connections while others were serendipitous. Participants also described variability in the content
of their mentorship, with some mentors focusing on participant’s practical needs as residency
applicants, while others focused on the complex issues surrounding race and racism.
Barriers to Mentorship
Although participants described many successful mentoring relationships, they also
described a wide variety of challenges. These challenges ranged throughout the continuum of
identifying potential mentors as well as connecting, establishing, and maintaining a relationship.
While many of these challenges were attributable to external factors specific to the specialty or
institution, participants also described beliefs that created internal/personal barriers to
connection.
Institutional Barriers
The challenges of accessing mentors starts with institutional barriers. As described
earlier, there was a significant institutional variability in the available resources. Many of the
participants had no available mentors in their chosen field within their institution. These
participants had to proactively search out potential mentors from outside institutions. Latrelle
stated:
I reached out to a cardiac cardiothoracic anesthesiologist at XXXX University. … She
was at the time she was the director of the residency there … I reached out to her and told
her I was interested in anesthesiology because [HBCU] didn’t have their own anesthesia
residency program.

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This approach not only requires the subject to not only have identified their interest, but also
have an awareness of the lack of institutional resources as well as have the initiative to fill their
needs. Kaydron described his rationale for connecting with his outside mentor.
I was just like, online, like emailing people, like, you know, professors, and just like
looking online … [at my institution] if you want to do surgery, like you’re gonna have to
be a lot more proactive than if you wanted to do a primary like department primary
care … knowing like, what other people have gone through … if I wanted to do this, I
was going to have to be like, the driving force behind it.
Even when the school had the department of interest, the faculty, and the department
varied in their interest and willingness to mentor students. Narquise noted:
[My school has a] very large department of ophthalmology … And that was like, I didn’t
find anyone to like, take me under their wings or mentored me. And after, even after like
three years, like, it took me for me to be in my ... applying for residency and spent many
years in the department … I always felt people were disinterested. Every time I asked,
ask for help ... they didn’t really have time for me.
These differences were not necessarily specific to the field. While Herold had a neurosurgical
mentor who was proactive and committed to mentorship, Bradley described the neurosurgeons at
his institution as “very, very aloof and very, very cold.”
Many of the participants expressed a specific desire to have a Black mentor. This
preference presented an additional institutional barrier. Except for the HBCU/Minority serving
institutions, Black faculty were underrepresented. This was further amplified in specialties with
low rates of Black representation. Both Gregory and Narquise had no Black faculty in the field
of interest. Even when participants were able to access Black faculty, they found that they were

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stretched thin “the only person who’s like a Black man in Peds who’s like really kind of in a
mentorship capacity is also a mentor to like 20 other people (Irvin).”
Cross-Racial Mentorship and Mentor Based Barriers to Connection
Underrepresentation at the institution and within the field often makes cross-racial
mentorship necessary. While the subjects’ experience with Black faculty was marked by a
commitment to mentorship and an ease in their connection, subjects’ experience with cross-racial
faculty was variable. While several participants had effective and supportive cross-racial
mentors, participants also described experiences that ranged from ineffective to overtly hostile.
Connecting with cross racial mentors was rarely spontaneous. Participants described how
connecting to cross-racial faculty required deliberate effort. This was true even in situations
where the subject had demonstrated a commitment to the field, a high level of performance, and
ample opportunity to connect, participants had difficulty connecting with cross-racial faculty.
Antonio stated:
And there’s a reason why of my three non-chair, letter writers letter writers all are people
of color … I worked with, I can say probably 20 plus 20 plus White surgeons throughout
the course of like, clerkship year, and it all somehow, for the subs, the three that I pulled
are the people of color.
Even when participants were able to engage the potential mentor in conversation,
multiple participants described how their interactions were marked by discomfort. Irvin describes
“you could tell when the other person is like uncomfortable, right? I need to feel comfortable just
like talking to you as like a person.” Bradley recalled an especially demonstrative example. He
was introduced to a person who was practicing in the uncommon and highly competitive surgical

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subspecialty that he was interested in. Over email, this potential mentor was excited to meet him
and enthusiastic about providing him guidance and mentorship.
And he responded, like so enthusiastically, and he was just like, “Let’s have coffee like
today.”… I went to the coffee shop, and he’s looking around. And, like, I was like, hey,
like, um, you know, I’m [expletive] blah, blah. He was like, “Oh, you’re [expletive].” I
was like, yeah. So, then we sat down and like, our conversation was, like, really sluggish
to get going. And it was just like, really tough … it was just like a really bad
conversation. I felt like I did something wrong … [I wasn’t] who he was expecting. I feel
like I didn’t even get a chance to like, make an impression even I feel like I just made by
showing up.
Although participants described this discomfort when they were seeking practical
guidance, it was especially notable when the topic of discussion intersected with race.
Participants commonly encountered lack of skill in engaging in racially aware conversations.
Potential mentors often avoided discussing race even when it was relevant to the discussion.
Irvin noted:
It’s always been that like, discomfort in that. And whenever it comes up, very much like,
oh, these are my talking points. Oh, like, it’s like, that is how I’m allowed to speak about
race, because that is the way in which it is comfortable, and, you know, acceptable. And
it’s like, ma’am, or sir, I am aware that I am ... I’ve been Black my whole life.
Participants also saw faculty’s lack of skill and comfort being expressed when race was brought
up in an inappropriate or irrelevant manner. Olin describes this as “dissonance happens between
me and other people is like, just like, kind of bringing it up. Like you can tell when people bring
it up to assuage their own guilt.”

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Mentee-Based Barriers to Mentorship Self-Reliance and Armor
The barriers to mentorship were not exclusively environmental or mentor-based.
Participants described a variety of mentee-based barriers to mentorship. They described a
hesitance to reach out for guidance and mentorship and questions about its utility. When they
chose to reach out, they felt unsure of how to do it. Both were seen as an outgrowth of both their
need for self-reliance and self-protection.
Several of the participants described themselves as both independent and self-reliant.
While some participants saw these as personal traits, others saw these as cultural traits that grew
out of their upbringing. Within this context, hard work and self-reliance were the keys to success.
“I’m that type of person to keep my head down and just do the work and, and, and good things
will come to you that sweat, you know, kind of what my mom taught me for sure (Herold).”
While participants recognized how these values were foundational to their success, they
also recognized how they were holding them back in this environment. They recognized both the
limits of self-reliance and the need to ask for help. “[I thought] I can do it all myself. No at all.
But, of course, you start really get you start getting humble very soon (Herold).” They also saw
how these values pushed them away from networking and mentorship and made them hesitant to
reach out to potential mentors. Bradley stated:
[My mentor said] look up and see that there’s things that are happening around you ...
you thought, this is like this unbiased process that you just sort of like, like you said, put
your head down and do it … things become more and more personal and interpersonal.
Like, they don’t become more bookish … [He’s] trying to sort of teach me … how
networking and social connections were valued in this environment.

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When participants identified the importance of asking for help, they described feeling
unprepared to do so. This was especially evident when participants were reaching out to potential
mentors. Many of the participants felt that they lacked the “soft skills” to connect with potential
mentors. Jamyron said:
I didn’t know if I didn’t know exactly what I was pitching for someone to be a mentor,
like, I was very unaccustomed to what that relationship looked like how close or distant
to be, how vulnerable you were to be with that, you know, attending or that person .…
Growing up, like, from my like, minority community, this wasn’t something that was like
common … I just didn’t know how to pursue that.
Participants saw these difficulties as not only common amongst URiM students, but saw this as
contributing to racial/ethnic disadvantage. “There’s definitely some cultural difference within,
you know, you know, particularly Black people, White people, Hispanic that definitely could,
you know, put us behind, but it’s behind the ball a little bit (Herold).”
Participants’ experience with racial hostility was seen as contributing to barriers to
connection with mentors. Participants described various racial hostilities from patients, students,
nurses, and physicians that ranged from subtle to overt. At the same time, they felt that they had
very few effective options for how they responded. They also saw confronting, engaging, and
even reporting these hostilities to be ineffective. They also felt vulnerable in their role as
students. Markael described his uncertainty of how to respond to an overt macroaggression.
The most powerful people at [hospital] are White men and White women. I mean, I was
even fearful of putting anything down on our, you know, evaluations, because to me, it’s
such a small community, that I don’t really trust the anonymity. You know, it can get

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around and once you get around, that’s, that’s it … I’m not gonna say anything. I don’t
want to risk my potential future because of such an interaction.
Several participants described how they simply developed a thicker skin to protect
themselves from these hostilities. However, they also acknowledged the limits to this approach.
As Bradley states, “I literally used to think I was sort of like, impervious to negative input .…”
Within this context participants identified the need to minimize the risk of these interactions by
being deliberate about the content of discussions in casual and formal interactions. Bradley,
Faizon, Irvin, and Olin described how they specifically avoided talking about their interests with
anyone outside of their trusted circle. This avoidance even extended to potential mentors. Elijah
saw the available resources but avoided reaching out. “I feel like there’s been like help, but at the
same time, I’ve been kind of hesitant, because the help that kind of got received. There were like,
underlying, like, microaggressions (Elijah).”
In addition to avoidance, participants also employed skepticism and caution when
considering the truth or validity of guidance or advice. They saw the need to be cautious even
when the message had positive intent or came from a person of authority. Olin commented:
[I] try to tread a little more carefully after that [racially hostile interaction]. And I use the
word of mouth of people that I really trusted … I didn’t listen to everything … I screened
a lot of because I think I learned I had to learn very quickly that like you can’t just listen
to everything that school says and do everything in schools is verbatim and be
successful.
Similarly, Bradley chose to reject any critical statements, rather than to spend the energy
deciphering the intent or underlying intent.

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There’s some people that I’d tell [about my career plan] immediately, they’re just like,
well, are you sure? I’m like, okay, well, I’m just not going to talk to you anymore …
they’re probably just like, [expletive], like, don’t you want to go home? ... sometimes it’s
just, they’re looking out for me, but to me, it just feels like they’re being like … you can’t
do it.
Although these approaches kept participants safe, they also closed participants off to potential
mentors and networking.
Black Mentor Advantage
Although participants described a variety of both racially concordant and racially
discordant mentors, they identified multiple advantages to Black mentorship. While participants
described internal and external barriers to mentorship, they also described the multitude of ways
in which Black mentors were able to lower and traverse those barriers. These advantages started
with the initiation of the relationship.
While there was variability in how enthusiastic cross-racial faculty were about mentoring
participants, Black mentors were consistently enthusiastic and committed to mentorship. Even
when Black mentors were extremely busy, they made it a point to make time for the mentees.
Olin noted:
There are a couple Black surgeons on staff that I’ve been trying to reach out to one just
never responded to my emails. Very busy … [he] then finally responded, randomly
respond to one of them. Like, a few minutes after I sent it … and now he’s another one of
my biggest mentors.
Black faculty were committed to mentoring the participants even when the mentor was in a
prominent position, from a different institution, or across specialties. Latrelle stated:

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I literally went on [website of outside institution] I was scrolling … I knew I wanted
someone of color, someone I could relate to … she was the director of the residency
program at the time … I, you know, just reached out, send her an email and luckily, she
was, you know, open and receptive ….
Participants also described an ease in establishing and deepening connections with
mentors. While many of the cross-racial interactions were marked by discomfort, participants
described an inherent trust and ease of connection with Black mentors. “There's just the, the
sense of, like, shared experience and belonging … we clearly have like a mutual recognition, and
he, he wants to help me (Bradley).” The ease of connection was also aided by having shared
experiences and interests outside of medicine. Elijah discussed how he initially connected to his
mentor because of a shared background of attending undergraduate schools in the same primarily
Black southern sports conference.
Proactive Mentoring
Black mentors were notably proactive in several aspects of mentorship. While many
mentoring relationships were initiated by the mentee, Antonio, Bradley, Herold, and Olin’s
relationships were initiated by the mentor. The mentors’ proactive nature was not limited to the
initiation of the relationship. Olin described how his mentors were attuned to how and when he
might struggle and contacted him in an anticipatory fashion. Antonio and Herold described how
their mentors saw how they were falling afoul of racialized expectations on their clinical
rotations and proactively provided them with racially aware “corrective guidance.” Antonio said:
I love you, I think you’re smart, I think you’re on the ball, I think you’re great. But I can
tell that the attendings and fellows and residents have a mixed opinion about, you … you
need to know, how to prepare for a case, and how to act and to talk, and to say, to bring

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up these questions … But like, with them, it has to be like, you’re engaging with them in
this certain sort of way. That’s like an agreed-upon thing. Whereas when I was with,
especially the people of color surgeons, it was just like, Do you know the answer? Yeah,
I know the answer.
Black mentors were also proactive in maintaining the connection and communication. “[My
Black mentors] are the ones that … that reach out to me to check on me, even it like without
prompting from me. And I think that that is also kind of important to me as well (Olin).”
Mitigating the Negative Effects of Racialization
Participants not only noted advantages in connecting with Black mentors, but they also
noted advantages in their mentorship. This advantage was most notable with regards to their
guidance for the racialized aspects of medical education. Black mentors were seen as not only
uncovering racialized expectations, but also creating a counter-narrative about Black men in
medicine.
Black mentors interacted and guided the participants in a racially aware manner. In
contrast to cross-racial mentors, Black mentors were consistently willing and able to have
discussions about and relating to race. They had first-hand experience with racial reality and
were well positioned to guide them through both their practical and racialized challenges and
concerns. Bradley noted:
We also get to talk about, you know, things that like, I wouldn’t necessarily get to talk
about somebody else with, you know, he could say, like, you know, that program is like
this and like that. And so maybe be careful, like asking these kinds of questions or
whatever, like.

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Black faculty mentors were also in the position to not only understand the unwritten rules
of the environment but also understand the racialized nature of those rules. Black mentors not
only uncovered those rules, but they also guided participants around the associated pitfalls.
Herold commented:
Okay, as I said, I said a very informal word during my, when I was rounding [with the]
attending[s] ... all of them older White males. He took me to the side saying, “you have to
be absolutely perfect ... try your best and perfect in my eyes, these, these White
leadership, and because they will take every bad thing that you do even if you’re even
one day …” I think I said “very cool,”, or something like that … it really connected with
a given understanding.
While participants described the expectation that Black men were expected to enter
primary care, Black mentors’ presence in the various specialties was seen as a counter-narrative.
This was especially true in fields with significant Black underrepresentation. Participants
described how just their visibility was enough to spark a student’s interest and draw them
towards specialties they had not been considering. Herold stated:
You know, I think one reason why I really gravitated to, you know, emergency medicine,
I think initially ... The person that was out selling it, was so charismatic, genuine, very,
very real is a Black man … it’s hard for somebody, you know, to gravitate to a specialty,
when you don’t see people that you could, you know, that looking not only just looks like
you, but she like you could, you know, connect with.
Beyond their presence, Black mentors were described as providing clear counter-
narratives. They expressed a belief that Black achievement was expected and not surprising.
They combined this with messages of ability and empowerment. Olin stated:

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So, everyone I asked so far. Before it was just like, oh, yeah, you know, like, you got to
have gifted hands, you know, you better you better like be gifted in school … [they] were
the first people who told me, like, “No, you absolutely can, like there’s nothing stopping
you … it’s very much well within your control, if it’s what you want to do.
Black mentors combined these with high expectations and frank assessment of the student’s
ability and areas of improvement. “He's been helpful as far as just being honest, being brutally
honest with me. And I appreciate that and he’s definitely someone who I don’t feel I can’t reach
out to him as far as like feedback or advice (Elijah).”
Black mentors also countered messages of racial duty and obligation. Participants
described how there was an implicit expectation that they would serve as a racial educator and a
racial trailblazer. Black mentors saw the importance of standing up against racism, but also saw
the personal toll of that role. Mentors encouraged participants to be deliberate about the role they
would play and to consider the benefits of standing up against the personal cost. Faizon said:
I came back probably from like, a tough day on the wards. And maybe a nurse had turned
to me, weirdly … “did you get paid to teach her that? ... you’re not everyone’s teacher.
Like, for your own like, well-being? Sometimes you’d have to be like, you know what,
you’re dumb. I’m gonna go this way. That’s it. Like, it’s okay. You’re not gonna fix
them.
Mentors worked to relieve the participants of their sense of duty to be a racial trailblazer and
encouraged them to prioritize their own needs. As Olin’s mentor states, “You can't die on every
hill, the most revolutionary thing you can do is graduate.”

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Peer Mentors
Although the traditional concept of a mentor is a senior faculty person, participants
identified the key role that near-peer mentors played. These peer mentors are primarily Black
men who were either upper class medical students or junior residents. Although these mentors
could be simply considered peers, these participants clearly and explicitly identified them as
mentors. Antonio stated:
Yeah, so, I would say that the biggest mentorship I kind of obtained in orthopedics was
peer to peer mentorship, the people who are roughly two years older than me, there’s one
friend who’s who I’m close friends with, I called him you know, today.
Participants identified multiple advantages to peer-mentors. Peer-mentors shared many of
the same advantages of Black faculty mentors. There was an ease in making and maintaining the
connection. There was an inherent trust and ease in the communication. However, they were also
seen as having advantages over Black faculty mentors that grew out of their proximity in age and
in training.
Proximity and the Ease of Connection
In contrast to subject-faculty dyads, participants described an ease in their mentoring
relationships that grew out of their proximity. Participants described how many of these
mentoring dyads were built on top of existing friendships. Participants described how they were
able to connect on both a peer and mentee level. Donovan states, “They know what we're going,
I'm going through, and it’s just easy to relate to them, complain together and whatnot … they
remember what it’s like.” This allowed for a connection and closeness that was difficult with a
faculty mentor.

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Accessibility and Communication
Participants commonly identified both accessibility and the flexibility of communication
as major benefits to peer-mentors. Participants talked about their hesitancy with reaching out to
faculty, citing the power differential, concern about being a burden, and their lack of experience
with communicating with faculty as significant barriers. Jamyron noted:
I think it was, it wasn’t like an explicit decision, it was more of who I could relate to
more. And see, like, there was a massive gap between like a program director versus like
me as like a student who might be like interested in and I felt more of, I didn’t want to
feel like a burden.
Participants also talked about how communication with faculty was typically both formal
and slow, which created an additional barrier to maintaining a connection.
In contrast to communication with faculty mentors, peer-mentors’ communication with
participants was described as informal, immediate, and flexible. This type of communication was
conducive to maintaining consistent communication. Elijah commented:
As far as like attendings I might initially reach out but then as far as follow up I might
you know, fall fall off in regards to follow up so just kind of compared to just being kind
of easier for me in our standpoint just staying consistent and just texting versus sending
emails.
Instead of saving up for a substantive conversation, these dyads were in more constant
communication. This was in turn conducive to discussing and mentoring across a wider range of
topics from the mundane to the substantive. Colton said:
So, I thought that reaching out to a student would help with sort of more practical aspects
of it. Versus I felt like going to a faculty first when give me as much practical knowledge

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for right now where I am right now, versus a student who has just been in my same place
recently.
Peer mentor proximity ensured relevance to their guidance. Many of these peer-mentors
attend the same medical school or training in the same environment. Many of them had identical
experiences. This allowed them to provide advice that was specific to the environment often in
an unvarnished and apolitical manner. Antonio commented:
Even [if] you are underrepresented, or minority attendings, I feel that the sauce has been
lost in many ways, you know, when they’re like, you know, 45 mid-career, they’ve been
in practice for 10, 15 years, it’s just the things have changed too much. There’s too, they
don’t really get it in some ways. They’re playing a different ballgame.
Synergy Between Peer and Faculty Mentorship
Although participants saw significant advantages to peer mentorship, it did not preclude
faculty mentorship. Both the participants and the peer mentors recognized the limits of peer-
mentorship and the advantage of faculty mentorship. Given the multitude of barriers to accessing
faculty mentorship, peer-mentors played an additional role as a bridge to accessing faculty
mentorship.
As mentioned earlier, participants described a hesitancy to reach out to faculty mentors
because it was seen as intimidating and difficult. At the same time, participants also questioned
the necessity of faculty mentorship. “So, I haven’t had that much mentorship, honestly, but I’ve
been doing fine without it, I think (Donovan).” Other participants saw their choice to not reach
out as an outgrowth of his self-reliance and independence. Herold noted:
It wasn’t an issue of kind of not having, you know, adequate mentorship … I wasn’t
really looking for it … I attributed it to my personality. Really, it was just a reserve

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independent thing. I can do it all myself. No at all. But, of course, you start really get you
start getting humble very soon.
One way in which peer-mentors served as a bridge to faculty mentors was by helping
participants overcome their hesitance to reach out. These peer mentors not only emphasized the
value of faculty mentorship, but they also placed the importance within the context of the
difficulty in access. Doing so they sent a clear message that faculty mentorship was worth the
trouble. Latrelle commented:
[My peer mentor] been telling me, you know, installing networking you need to reach
out, especially since [HBCU] doesn’t have an anesthesia residency program, like you
need to take the initiative and go after what you want … But it all starts with you taking
the initiative and letting people know.
Peer mentors also served as a direct bridge to faculty. Even when participants were
willing to reach out to faculty, they ran into barriers to access. Peer-mentors had a broader
network that they could leverage for participants. Gregory said:
Yeah, so I reached out to multiple people. A lot of them said no, or like not right now. Or
we have too many med students on projects. And eventually [my peer mentor] put me in
contact with them directly. And that’s when I got my first project started.
When peer mentors connected students to faculty, they did so in a racially aware manner. They
not only connected students to faculty that were knowledgeable, but could be trusted to interact
in a racially appropriate manner. Olin commented:
[One of] the people that they told me to reach out to [was] fantastic. One of them is a
current as a major mentor of mine and he’s he’s a White man, but he was... one of the
first things he said was like, “so, you want to do surgery?” I was like, yeah, I’m thinking

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about he’s just like “good because we need you.” And I really appreciated that. I think
that was the first time anyone had ever told me that.
Although it was unclear from the interviews what the quality of peer mentorship was, it is clear
that peer mentors filled a critical role in the participants’ development.
Successful and Positive Cross-Racial Mentorship
Although many cross-racial interactions were negative, participants described multiple
examples of successful cross-racial mentors. Successful cross-racial mentors varied across
multiple dimensions, including personal characteristics, style of communication, and content of
mentorship. Despite the wide variation, these pairs were able to overcome cross-racial
connections to establish meaningful connections.
As discussed earlier, participants described multiple challenges with connecting with
cross-racial mentors. Negative interactions with potential mentors were marked by a lack of
interest in mentoring, discomfort with cross-racial interactions, and a hesitance to engage in
conversations around race. Although successful cross-racial mentors varied in their gender,
position, style of communication, and the content of their mentorship, they were consistently
comfortable interacting with the participants and committed to mentorship. “And I hope I’m not
that this does not come off negative. But when you meet someone who is truly comfortable with
race and race discussion, you just know it (Markael).”
Successful cross-racial mentorship was characterized by the quality of the interaction
with the mentor and not the content. Although issues of race and racialization permeate the
subjects’ challenges, racially centered mentorship was not compulsory to successful cross-racial
mentorship. Both Antonio and Kaydron described how their cross-racial mentors focused on the

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practical aspects of choosing their field and applying to residency. In Kaydron’s case, his mentor
had awareness of the racialized challenges, but focused on Kaydron’s practical needs.
He is aware of, like, is aware of race. I mean, like, some of the projects that I’ve helped
on was just like about like, diversity .… So, I think through projects like that, he is aware,
and I mean, he is aware of like, racial disparities [within] vascular surgery. I don’t think
we necessarily had had an explicit conversation of me wanting to do vascular surgery,
and how that changes or how that looks as me being a Black male. But I mean, he has
helped me like as just like, a general like, like, like applicant, like what I need to do is
like a general applicant, when I need to do when it comes to interview season?
Participants also described examples of successful cross-racial mentors that mentored in a
more racially aware manner. These mentors mirrored one of the key aspects of successful Black
mentors. They had first-hand knowledge of differential expectation and differential evaluation
and guided the participants through that space. Bradley commented:
There was just a lot of like, little things that I was just like, not doing in formal settings or
something like that. And he was just like, look, people are gonna judge you for that. And
they shouldn’t, but you have to do them ... you know, say some university may deny
that … No, we don’t discriminate on our campus … someone is, like, helping me
understand that … someone that I really trusted was trying to help me.
They also provided a clear counter-narrative to both the deficit messaging and the message that
Black men should go into primary care through active encouragement. Olin noted:
He would bring, I would bring that up in the context of like, I feel like a lot of people are
telling me to do primary care, but I want to do this. And he said … Black patients are
seen by surgeons too. And they deserve to see people that look like you too … he’s kind

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of one of the first people that like, gave me an alternate voice … he kind of gave gave me
that piece of confidence .… And so, to have somebody who I considered like, a master of
this field of Titan of this industry, telling me that I was welcome and needed was was
very fulfilling.
Like how peer mentors facilitated networking, cross-racial mentors’ racial awareness
extended into how they facilitated networking. Cross-racial mentors recognized the value of
racially congruent mentorship and their inability to provide that support. Cross-racial mentors
have a preexisting network of Black colleagues that they could rely on to provide racially
congruent mentorship. Markael noted:
So, one of my [White female] mentors … I was telling her how much I love surgery. And
she was like, what mentors do you have? And I started listing them and she’s like, no
Black mentors. And she’s White. And so, we launched into this discussion, she had all
these people lined up for me.
Successful cross-racial mentors shared many characteristics with Black mentors. They
displayed comfort with interacting with participants, demonstrated racial awareness, and were
willing and able to engage in racially aware conversations. While many cross-racial faculty
lacked these skills, these examples demonstrate that cross-racial faculty can mentor Black
students.
Research Question 2
Research Question 2 asks, “How do African American/Black male medical students
resolve conflicts between internal beliefs and external expectations with regards to specialty
selection?” As discussed previously, many of the participants acknowledged the message that
they were expected to enter the primary care fields. They recognized that the rationale of these

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messages centered on a desire to maximize utility and meet the greatest needs. They also
recognized the reality of the primary care shortage, the racial health disparities, and the potential
role of Black primary care physicians in meeting those needs.
Despite this messaging, none of the participants pursued a career in primary care.
Although Faizon was pursuing an internal medicine residency, he was doing so with the
intention of pursuing specialization in rheumatology. Similarly, Irvin was pursuing a pediatrics
residency but with the intention of specializing in critical care medicine. These choices were not
simply due to not liking the primary care fields. Several participants specifically described how
much they enjoyed their primary care experiences.
Resisting External Messages and Internalization
As discussed earlier, the push towards primary care was both pervasive and ubiquitous.
These messages came from classmates as well as persons of authority in the medical school.
Participants had not only received and identified this expectation, but they also freely repeated
this expectation in the interviews. Despite this they were able to resist internalizing this message.
Instead of focusing on meeting external expectations and sense of duty, participants centered
their decision-making on their own interests and priorities. Latrelle commented:
Yeah, so even with interviewing and [HBCU], they kind of push you know, primary care,
that’s their whole objective is to get more physicians to go into primary care … I knew
that going in. But I didn’t necessarily take that to heart. Because I knew I had different
plans for myself.
Participants employed a variety of approaches to actively resist internalizing this
message. Even though this message seemed to come from an accepted truth, participants were
able to employ skepticism about its validity. As discussed earlier, participants recognized the

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racialized nature in how the push was preferentially directed at URiM students. This recognition
alerted participants about the need to be skeptical. Participants were able to parse the
components that did and did not resonate with them and reframe the push into a counter-
narrative that minimized the racialization.
Participants recognized that a central component of the push towards primary care was an
emphasis on service. This central core resonated with many of the participants who identified
service as a professional priority. Multiple participants described how they were not only
motivated to pursue medicine because of their first-hand experience with health inequities,
directly addressing those issues was a professional priority. “I saw [healthcare] being a dire need
in my community … having family members myself, battling with dire health outcomes. I knew
I wanted to do something to kind of help alleviate that issue (Elijah).”
Participants were able to reframe the push in a manner that maintained the focus on
service but was more inclusive of all fields in medicine. While they acknowledged the need for
primary care, participants had a broader view of the unmet needs within the Black community.
Donovan described the unmet mental health needs of his community:
[I am motivated] to give back to who I think are the people that need it the most, which
not just Black people, you know, immigrants, like other minority communities and other
just lower socio-economic class is, but that’s basically like, I guess the population that I
feel like needs that help the most.
Similarly, while participants also acknowledged that primary care was a path to providing
service to the Black community, they had a more expansive definition of service. As Jamyron
stated:

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I thought it was very naive of people to assume that you cannot give back by being any
other type of specialty besides primary care. It’s not like, minorities don’t need
anesthesiologist don’t need emergency medicines don’t need, you know,
ophthalmologists and what not.
This reframing allowed the participants to not only resist the dominant message, but to replace it
with a counter-narrative that allowed for alignment between their desire to pursue their interests
and to give back to their community.
For some participants, skepticism and reframing was inadequate. For them, this push felt
less innocent and more racially hostile. These participants interpreted the push within the context
of its primary care’s position within the medical hierarchy. From this perspective, this push was
seen as a push towards a subordinate position within medicine and an example of
marginalization and a reflection of racist beliefs about Black ability. Pernell noted:
Yeah, we do need more underrepresented minorities in primary care, even though we
need it in every specialty. It just seems like the expectation is more so for that basic
physician level. Similarly, to I guess, most industries right now, where we see racial
disparities between you know, the people at the high executive levels being more so
White predominant compared to underrepresented minorities filling the lower-level
positions. I think that’s seen in a lot of different industries, not just medicine.
Within this interpretation, skepticism and reframing were insufficient. It created an imperative to
actively resist and reject this message.
Even though participants employed various approaches to resist this message, the
ubiquity of the message presented additional challenges. Although reframing and rejection were
effective, some participants also described the need to employ avoidance. As described earlier,

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casual conversation about participants’ specialty interests created an opportunity for people to
either reinforce their expectations or question their ability to pursue a competitive specialty.
Bradley discussed how he recognized the potentially benevolent intention, and he found it
necessary to not only reject the message but to avoid situations that presented an opportunity to
inject self-doubt. He described his decision to pursue a competitive field as both difficult and
fragile, thus needing protection.
There’s some people that I’d tell [about my plans to pursue a competitive surgical
subspecialty] immediately, they’re just like, well, are you sure? I’m like, okay, well, I’m
just not going to talk to you anymore. I’m not sure. But I don’t really need. I need
something like circumspect, but not like, that makes me doubt … I realized, honestly, like
much later … “are you sure?” like all they meant was like, you know, it’s like really
hectic … it may not be like the lifestyle that you want. For me, I just hear like, doubt
about myself.
Multiple participants described a similar approach of limiting when and who they discussed their
specialty interests. “[The expectation that Black men would pursue primary care] was a pretty
pervasive theme that people that have always told me that or continue to tell me … I didn’t quite
tell anyone that I was interested in surgery (Olin).” Participants instead limited their discussions
to a trusted inner circle.
External Support to Resolve Internal Conflicts
Participants described the crucial role that racially aware mentoring played in resolving
the conflict between personal interests and feelings of racial duty to pursue primary care. As
described earlier, many participants had feelings of guilt about not pursuing primary care, a small
number of participants significantly struggled with resolving this conflict. Participants described

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how these mentors acknowledged both the push towards primary care and the feelings of racial
duty, but directly countered this narrative. These mentors did this by naming the racialized nature
of the message and guiding them to an approach that centered on their needs and priorities.
Jamyron stated:
[My mentor and I] had a very long conversation … feel more and more like … a selfish
decision to pursue like anesthesiology … we had a very long conversation on …
provid[ing] for my community in multiple ways, even as an anesthesiologist. Ways that I
could contribute to helping out my community so I thought it was a very eye opening …
he … impressed the importance of pursuing something that ... I can, you know, that I
enjoy as well as something that I can be an expert with[out] settling .… And I think these
were things that I knew. But like hearing it from someone who’s older who’s like
practiced medicine for multiple years, who’s very involved within like minority
communities helped me come to the decision.
This approach not only reflected these mentors’ understanding of racial reality, but also provided
an effective approach to guide mentees through these types of conflicts.
Summary
Participants came to medical school from a wide range of backgrounds, academic
pedigrees, interests, and priorities. They attended a wide range of schools that varied in the
clinical opportunities, primary care focus, and racial environments. They were pursuing a wide
range of medical and surgical specialties.
Despite this variety of background and educational environment, there was a consistent
racialized nature to their experiences. These included a medical education environment marked
by racial hostility, differential expectations, and differential evaluations. They found the fields to

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vary in how welcoming they felt to them as Black men. They described welcoming fields as
valuing and encouraging them to provide their differential perspective, while hostile fields
emphasized conformity.
This racialized nature extended into expectations about what fields Black men were
expected to pursue. Participants experienced a race-based, subtle, but consistent push towards
primary care as well as an expectation. Participants described the ubiquity of this message and its
rationale as creating a sense of racial duty or obligation to pursue primary care.
This sense of racial duty added an additional layer of complexity to their specialty
selection. Participants described being conflicted and even feeling guilty about pursuing their
interests instead of meeting their racial obligation. Despite this internal conflict, participants
were able to choose fields they not only enjoyed but in which they were able to project
themselves into the future. They did this by employing a variety of internal strategies to reject or
reframe external expectations as well as relying on the guidance of mentors.

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Chapter Five: Discussion and Recommendations
Participants’ stories provide insight into how they chose their specialty. In doing so, they
uncovered the racialized nature of their experiences and their influences. This section discusses
the key findings and provides corresponding recommendations.
Findings
Racial Duty in Medicine
Despite both public proclamations that schools are focusing on diversity, equity, and
inclusion, the subjects’ experiences in medical school continue to be racialized. They
experienced racial hostility and an evaluation system that was experienced as inequitable. These
mirror the current literature about URiM student, resident, and faculty experiences in medical
schools where their experiences are marked by marginalization (Osseo-Asare et al., 2018; Volpe
et al., 2021), differential expectations (Volpe et al., 2021), and racially based barriers to
professional development (Dyrbye et al., 2007; Osseo-Asare et al., 2018; Peterson et al., 2004).
In this study, one of the major components of this racialization is the push for Black men
to pursue primary care. This push to primary care was typically associated by a conceptual
linking of service, Black men, and primary care. Like findings in the literature (Kelly-Blake et
al., 2018; Pechura, 2001), these messages were seen as preferentially directed at the participants
and other URiM students and not towards their White colleagues. The end effect of this
messaging coalesced into a perception of a racial obligation or duty to pursue primary care.
This message stood in stark contrast to the predominant message that encouraged
students to explore and emphasized personal priorities and personal satisfaction. This message
was experienced as racially hostile. In contrast to race neutral emphasis on personal priorities,
the sense of obligation was experienced as restrictive, deemphasized autonomy, and

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reemphasized their marginalization. Although participants were able to avoid internalizing this
racial duty, it was still a lingering presence that injected doubt into their decision to pursue other
specialties.
Although this push was described as subtle, the message was clear. Even though none of
the participants were pursuing primary care, all but two participants expressed their belief that
Black men were expected to pursue a career in primary care. This push was also pervasive with
the messages coming from patients, staff, nurses, residents, and faculty. At the same time the
way these messages were expressed freely without any overt hostility reflected not only a lack of
awareness about the racialized effects of this messaging, but that they were expressing a
common belief.
This push towards primary care and the creation of racial duty through specialty selection
has not been well described in the literature. While the literature has documented that Black and
other URiM students are more likely to pursue primary care fields (Brotherton & Etzel, 2020;
Davidson & Montoya, 1987; Xierali, Nivet, et al., 2014; Xierali & Nivet, 2018), there is a lack of
studies investigating the reasons for this differential distribution. Although none of the
participants were pursuing a career in primary care, this racialized pressure is likely reflecting a
component of the hidden systemic beliefs that contribute to the racial patterns in Black students’
career choices.
Although this specific finding has not been well described, it aligns with other findings in
the literature. While there have been occasional warnings of the need to be careful about creating
an expectation that URiM students are accepted exclusively to meet the needs of minoritized
patients and the medically underserved (Kelly-Blake et al., 2018; Mcdade, 2021; Smedley et al.,
2001), this message has been relatively absent in the literature (Kelly-Blake et al., 2018). Instead,

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this dysconscious messaging reflects the current literature which “amplify and perpetuate
disproportionate service expectations for URM physicians” (p. 932 Kelly-Blake et al., 2018).
While it is possible that the racialized distribution among the specialties reflects
differential interests, from the framework of CRT, the push towards primary care, racial duty,
and the disproportionate service obligation are all elements of systemic racism (SR). SR refers to
the unequal opportunities and outcomes that result from the institutional and societal structures
(Banaji et al., 2021; Bonilla-Silva, 2008, 2021). Systemic racism often operates in an
unconscious manner that precludes the need for overt racism to result in racialized pressures or
outcomes (Bonilla-Silva, 2008).
Participants commonly describe the messages as being pervasive and being expressed
without hostility or obvious ill intent. Both the casualness of the messages and the pervasiveness
of the messengers give the appearance of the expression of a common and unexamined belief.
Further, the contrast between the push to primary care and the predominant message of “pick
what you like” reproduced marginalization by tying conditions to their access to the profession.
The lack of malice reflects a lack of awareness of the racially negative effects of this
message. This lack of awareness is also seen in the literature where the rationale for addressing
diversity in medicine centers on its potential to address racial and economic health disparities at
the expense of highlighting the multitude of educational, environmental, and institutional
advantages of diversity (Kelly-Blake et al., 2018). As a testament to this centering, the paper by
Komaromy et al. (1996) that first documented these effects has been cited more than 1000 times
(Google Scholar, n.d.).
The hidden nature of this racial hostility underscores the concept that positive intentions
are insufficient to achieve progress in DEI in medicine. Although the service argument for

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diversity is based on empiric data, easily understood, and easily justifiable, the manner in which
it recreates marginalization and the solidification of the current argument for diversity stands as
an impediment to continued progress. These findings also underscore the importance on
centering on minoritized voices. Doing so not only leads to a deepened understanding of their
experiences, but also uncovers the negative influence of systemic beliefs. As individuals work to
achieve progress in DEI, these findings serve as a reminder that there is a need to intentionally
examine messages for unintentional reproduction of racism and marginalization.
Positive and Negative Environments in the Specialties: Best Practices and Cautionary Tales
Although all the fields have espoused the benefits of diversity, in this study there was a
large variation in the subjects’ experiences in each of the fields. Psychiatry stood out as a field
that not only actively recruited participants, but was also experienced as especially welcoming to
Black men. Participants described how psychiatry care teams not only accepted diverse
perspectives, they encouraged participants to leverage their differing views to optimize care.
Clinically, psychiatry was also seen as a field that was racially aware—they saw the direct
influence and relevance of race and culture on the patient’s disease process, progress, and
treatment. This emphasis is reflected in the psychiatric literature that not only acknowledges the
relevance of race and culture throughout the entire spectrum of psychiatry, but also emphasizes
the importance of cultural humility and the commitment to life-long learning about cultural
differences (F. A. Moreno & Chhatwal, 2020).
Subjects’ experience in psychiatry stands as a stark contrast to the othering and the
suppression of personal identity that has been described in the literature (Osseo-Asare et al.,
2018; Volpe et al., 2021). While URiM students have described how they leveraged their
“outsider” status to produce positive interactions with marginalized patients, they were rarely

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lauded or recognized in their evaluations (Volpe et al., 2021). In contrast, as described earlier,
Kaydron stated “my being a Black being a Black male was more emphasized, especially in the
patient population to see me … I felt like my opinion, or my perspective was valued more in that
rotation.”
Psychiatry provides lessons for fields that are interested in increasing the diversity of
their fields. Not only did the field espouse a commitment to diversity, but they also recruited
URiM students into a field that had an inherent awareness of cultural differences in perception
and conceptualization, both from the patient and the physician perspective (F. A. Moreno &
Chhatwal, 2020). This understanding was seen as extending to their approach and treatment of
medical students. They embodied an understanding of the diversity advantage and created an
environment that not only accepted diversity, but celebrated it and saw it as a path to optimal
patient care.
In contrast to psychiatry, OB/GYN and orthopedics stood as fields that were experienced
as being especially unwelcoming. Both fields were seen as having a strong and distinct
clinical/educational environment that was seen as especially inequitable and hostile. Participants
described a difficult combination of an environment that emphasized conformity, but whose
expectations were hidden and tacit. In contrast to psychiatry, where participants were encouraged
to bring their whole selves to the clinical space, participants in both OB/GYN and orthopedics
described the feeling that “I felt like I couldn't be myself or express myself or talk the way I
wanted to” (Latrelle).
In both fields there is a distinct lack of literature describing this differential perception of
Black men. Although the “jock and fraternity” culture of orthopedics is seen as a potential
deterrent to female medical students (Miller & LaPorte, 2015), there is a lack of awareness how

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the same cultural elements could be a deterrent to Black males. Instead, the diversity literature in
orthopedics focuses on the lack of Black mentors/role models and bias in the application process
(Ode, Bradford, et al., 2021), while the inclusivity is seen as an institutional issue and not a
global one (Ode, Williams, et al., 2021).
Subjects’ experiences on OB/GYN are more complicated. Although all the direct
negative interactions were with White female physicians, participants described being unsure of
the relative contribution of race and gender in their conflicts. Subjects’ attributional uncertainty
is understandable. There is a perception among male medical students that their clinical
experience and their evaluations are negatively shaped by their gender (Emmons et al., 2004).
This is echoed by a recent survey of practicing OB/GYN physicians, who expressed sentiments
such as “There is no place [for men] in OB/GYN” and “Being a male OB/GYN is akin to being a
dinosaur” (Long et al., 2018). Given this baseline of gender bias, further studies are needed to
characterize Black male student experience in OB/GYN and the intersectionality of race and
gender.
The participants’ experiences demonstrate how exclusion can occur without intent. The
dyad of orthopedics and OB/GYN emphasizes conformity and assimilation, which CRT scholars
identify as a form of subjugation and systemic racism (Solórzano & Yosso, 2002). The emphasis
on assimilation builds on the subordination of the non-majoritarian perspective (Matsuda, 1991)
and further solidifies marginalization. Although there were participants who attributed general
openness of a field as an outgrowth of the required skills of the field, there is no clear need or
advantage to the racial or gender hostility in these or any field. As the participants demonstrated,
the environment of exclusion only stands to limit the potential pool of interested students.

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As discussed above, psychiatry stands as a stark contrast to OB/GYN and orthopedics. It
is unclear, from this study, how or why psychiatry developed a more inclusive environment.
Psychiatry has a similar history of racism that the American Psychiatric Association (APA)
recognizes “… laid the groundwork for the inequities in clinical treatment that have historically
limited quality access to psychiatric care for BIPOC.” (psychiatry.org, n.d.). Regardless of the
process, it is clear from the participants that the embrace of the relevance of psychosocial factors,
including race, in the clinical care of patients has also been embraced by the educational
community. Psychiatry’s celebration of diverse perspectives stands not only in contrast to the
emphasis on assimilation, it provides a roadmap for fields like OB/GYN and orthopedics to
create a path towards a more inclusive, welcoming, and diverse environment.
Mentorship and Black Male Professional Development
Subjects’ racialized experiences and the racialized push towards primary care add
additional complexity to their career choices. While this added complexity underscores the
potential role and need for effective mentorship, several participants described their hesitation
and reluctance to reach out to potential mentors. Some participants not only described their
inexperience and unfamiliarity with mentorship, but they also felt that they lacked the “soft
skills” to connect and sustain those relationships. Other participants’ reluctance was driven by a
desire to avoid a repeat of past negative cross-racial interactions.
Many of the subjects’ key mentors were Black physicians, residents, and peers. Like all
the successful mentoring relationships, these mentors fulfilled the participants’ needs for
practical advice and guidance. Their relationships had several distinctive features. Participants
described a mutual respect and trust, a shared understanding of racial reality in medicine,
interactions free from racial hostility, and a willingness to engage in racially aware discussions.

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Not only were many of these mentors committed to mentorship, but they were also proactive in
engaging with potential mentees and proactive in their guidance.
Within Black mentors, participants identified the key role that peer-mentors played. All
these relationships grew organically and not from peer-mentoring programs. Not only did peer-
mentors share many of the key qualities with other Black mentors, but they were also seen as
having distinct advantages over faculty mentorship. Compared to faculty mentors, participants
found that the flexibility in communication and the professional proximity allowed for more
consistent communication and guidance over a greater range of topics. In this manner the peer
mentors provided insight into additional best practices in mentorship.
The role of peer mentoring in medicine has not been well described. A recent systematic
review of peer-mentorship in graduate education found peer-mentorship to be an effective
method of improving knowledge, psychological well-being, and a sense of community
(Lorenzetti et al., 2019). Within medical education there is a single study of a formal peer-
mentoring program between URiM residents and medical students. In this study, peer-
mentorship was found to be well received by both mentors and mentees (Youmans et al., 2020).
The findings from this study and the current literature point to the utility of peer-mentorship in
supporting URiM students. Further studies are needed to characterize these relationships and to
identify structural interventions that can encourage and enhance these relationships.
Despite the effectiveness of Black mentors, many of the participants felt that they had
inadequate mentorship. This finding is reflected in the literature where Black students and
residents feel that they lack sufficient mentorship (Osseo-Asare et al., 2018). This may reflect
both the structural barriers to accessing Black faculty as well as the inadequacy of cross-racial

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mentors. Both the subjects’ experiences and the literature underscore the need for increased
faculty capacity to mentor Black men.
Participants’ experience with cross-racial mentorship reflect several findings in the
literature. Like the service-diversity connection experienced by the participants, medical school
faculty of color are burdened with a greater proportion of “service” obligations such as
mentoring of minority students (Cyrus, 2017; Jordan, 2011; Page et al., n.d.). Although there
have been a few authors who have called for faculty of all identities to take responsibility for
mentoring URiM students (Cyrus, 2017), the literature and this study seem to reflect an
expectation that URiM student mentorship is the responsibility of minority faculty.
It is unclear from this study what was cross-racial faculty’s rationale for not engaging in
mentoring participants. Participants attributed this reluctance to a variety of reasons, including
lack of skill and/or discomfort with cross-racial interactions. Although it is possible that these
faculty lacked skill of comfort with cross-racial interactions, the findings in this study clearly
show that cross-racial mentorship is within the ability of non-minority faculty. Not only were
there examples of successful cross-racial mentors, none of the skills that Black mentors
employed were racially bound. If all faculty have the capacity to mentor across identities, there is
no reason that Black and URiM mentorship cannot also be a collective responsibility.
Recommendation for Practice 1: Increase the Capacity for Black Medical Student
Mentorship Through the Training of Cross-Racial Faculty
This study highlights the inadequacy of the capacity for Black male mentorship in
medicine. Black men in medicine face challenges above and beyond those of their non-URiM
colleagues. Simultaneously they also face race-based barriers to mentorship. Black mentors
reliably provide quality mentorship, but access is limited by representation in both the field and

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within the institution. Although there are more potential cross-racial mentors, access is limited
by faculty skill and comfort with cross-racial interactions.
The inadequacy of mentorship is also seen in the literature. Black and URiM students,
residents, and faculty are less likely to have mentors or be satisfied with the mentorship they
receive (Bonifacino et al., 2021; Nivet et al., 2008; Ramanan et al., 2006). Junior URiM faculty
report difficulty finding mentors who are committed to their success (Ramanan et al., n.d.;
Palepu et al., 1998). These findings are seen as contributing factors to the gaps in URiM faculty
retention and career advancement (Beech et al., 2013).
Participants described a variety of effective mentors. In this study, Black mentors were
especially effective in providing mentorship to Black men. However, it is important note that
what they did and what made them effective are not racially bound. Many of the successful
cross-racial mentors implemented similar approaches and attributes: mutual trust, a commitment
to mentorship, proactiveness, comfort with interacting with Black men, and comfort with racially
aware conversations. These are all behaviors and capabilities that are within the capacity of all
faculty.
Although the intuitive solution to increasing mentorship capacity is increasing faculty
diversity, it cannot be effective by itself. Racially aware hiring is expensive, politically, and
logistically difficult, and slow. Smaller institutions, smaller departments, and fields with limited
national representation have large barriers to making substantive improvements in diversity.
While efforts to increase faculty diversity are important and necessary, they are inadequate to
meet the current and immediate need for URiM mentorship.
Considering the immediate need for increased capacity, the ideal solution combines
racially aware hiring with faculty development aimed at equipping all faculty with the skills to

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mentor across racial and ethnic identity. This shift would not only be more immediate, but it
would utilize current resources and would be applicable to a broad range of departments and
institutions. This would also likely have the added benefit of increasing the overall mentorship
capacity of the department or institution, as well as decreasing the negative effects of the
minority tax on current Black faculty.
This intervention centers on the goal of creating a community of practice (Lave &
Wenger, 2012). The goal is to not only develop the faculty but to create a community of people
with a shared interest that would not only serve as a place to exchange thoughts and ideas but
could also support the development of motivated newcomers (Lave & Wenger, 2012). The initial
focus will be on the development of faculty who self-identify as being motivated to gain skills in
cross-racial mentorship.
This intervention will center on three main components: increasing comfort with cross-
racial interactions, increasing racial awareness, and building ability and comfort with racially
aware conversations. This intervention will center on the CRT approach of counter-storytelling
to not only reveal the racial reality in medicine, but to also dispel beliefs about Black mentorship
and encourage a collective responsibility for Black mentorship. This intervention will rely on
Black faculty, residents, and students from the organization to provide these counter-stories. For
storytellers who are worried about their anonymity and/or their personal or psychological safety,
the stories will be presented by a different member.
The community of practice model has several additional benefits. It creates a forum that
can foster peer-mentorship between faculty. Additionally, identifying persons who are able and
motivated to provide mentorship for Black men would improve the ability for faculty to connect
mentees with mentors who could be trusted to mentor Black men.

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This intervention is implementable on an institutional, regional, and national level.
Specialty level interventions could be implemented through national specialty societies. This
intervention has an especially high potential for impact in the highly competitive specialties.
Black students’ and trainees’ access to mentors is limited by representation. Because of the low
rates of Black representations at the applicant (NRMP, 2022), trainee (Brotherton & Etzel,
2020), and faculty (AAMC, 2019a) levels, there is a pointed need for cross-racial mentorship
capacity.
In addition, the lack of representation in the fields is exacerbated by the fact that many
institutions do not even have any physicians in these fields. Most notably, none of the HBCUs
and minority serving institutions have departments of neurosurgery, ENT, and urology. Howard
is the only one of these institutions with departments of dermatology, ophthalmology, and
orthopedics (Morehouse School of Medicine, n.d.; Charles R. Drew University of Medicine and
Science, n.d.; The City College of New York, n.d.; Howard University College of Medicine,
n.d.). Specialty level interventions not only can increase mentorship capacity in fields with low
representation, increasing mentorship capacity on a national level increases the ability to meet
the mentoring needs of all mentees regardless of their institution size or location.
Recommendation for Practice 2: Strengthen and Solidify Peer-Mentorship
As noted above, current capacity for Black mentorship is inadequate. The findings of this
study uncovered the central role that peer-mentors played in the professional development of
Black men in medicine. This type of mentorship was seen as having distinct advantages over
faculty mentorship in the proximity, relevance, and accessibility of the mentors. Although there
may be a tendency to describe or dismiss these relationships as peer-support participants, they
were clearly identified as a legitimate form of mentorship.

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While there may be a concern about peer-mentorship supplanting faculty mentorship, in
this study peer-mentors played a complementary role. Participants described how they were able
to overcome their hesitation about reaching out to faculty because of peer-mentors emphasis in
doing so. Similarly, there were multiple examples of mentoring relationships that were the direct
result of facilitated networking by the peer-mentors.
Given the important role of peer-mentors, there is a need for interventions that will not
only encourage the formation of these bonds, but also ensure the quality of the guidance. While
affinity groups have been an effective tool for peer-support, peer-mentorship requires a mix of
expertise and seniority. Youmans et al (2020) described an institutional approach to supporting
peer-mentorship relationship formation. In their intervention, they brought URiM residents and
medical students together in regular sessions that included course reviews, panel discussions, and
social events. Not only was this approach effective in encouraging the formation of peer-
mentorship, this approach of leveraging institutional human capital is reproducible at other
institutions.
This type of structured intervention to support peer-mentorship has additional
advantages. While there are concerns about the quality of the guidance, these structured sessions
provide a forum for faculty to ensure that peer-mentors are equipped with the appropriate
information. These sessions also have the potential to play a complementary role with the
intervention to increase faculty capacity for Black mentorship. These sessions provide a forum
for motivated faculty to interact with potential mentees, which would not only be an opportunity
to interact with potential mentees, but to also increase faculty comfort with cross-racial
interactions.

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Recommendation for Practice 3: Address Mentee-Based Barriers to Mentorship Through
Pre-Matriculation Programs
To realize the full potential of increasing institutional and specialty mentorship capacity,
mentee-based barriers to mentorship need to be addressed. Multiple participants discussed their
hesitation and aversion to faculty mentorship. Even when participants were interested in
mentorship, they often expressed that they lacked the “soft skills” to effectively engage with
mentors. While participants had faculty that expressed a desire to mentor them, they expressed
their hesitation because they didn’t want to bother them. These findings are consistent with
sociology and education literature that increasingly recognize the role of social norms and
socialization as barriers to mentorship (Jack, 2019; Ramirez, 2011).
Mentee-based barriers to mentorship have not been well described in the medical
education literature. This lack of awareness can lead to misunderstanding by potential mentors.
While a mentee not reaching out to faculty can be interpreted as a lack of interest, it may reflect
mentee hesitation. While the traditional model of engagement is for the junior person to reach
out to the senior person for guidance, mentor-based barriers may require faculty to be more
proactive in expressing their motivation to mentor and in connecting with potential mentees.
Mentee-based barriers to mentorship can be addressed through pre-matriculation
programs. Such a program would focus on uncovering the unwritten norms of academic
medicine, countering student’s counterproductive beliefs about mentorship, and undermining the
legitimacy of racialized expectations. This would also be a place where the schools can help
them to develop the soft skills that many of them expressed that they lacked.
This intervention has the potential to play a complementary role with the other
interventions. Faculty participation, especially from competitive fields, would help to disrupt

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racialized expectations about their career choices. It also provides access to students who would
otherwise have trouble overcoming barriers from underrepresentation in the specialty
Although programs to address Black student barriers to mentorship have not been
described in the literature, there have been several reports of pre-matriculation programs for
“educationally disadvantaged” students aimed at addressing knowledge deficits and academic
skills (Grumbach & Chen, 2006; Kosobuski et al., 2017). Similar programs have been
implemented at multiple medical schools, including Wright State, University of Louisville,
Rosalind Franklin University, and others (Wright State University, n.d.; School of Medicine
University of Louisville, n.d.). Although these programs and others focus primarily on academic
preparedness, they present a pre-existing structure where this content can be introduced.
Limitations and Delimitations
It is important to identify several limitations to this study. As with all qualitative studies,
this study will lack generalizability. The data only reflects the participants’ individual
experiences, thoughts, and beliefs. Although the findings are suggestive of a more universal
experience for Black men, those need further quantitative studies. Although Black men’s
identities are often dominated by their racial identity (Noguera, 2003), it is equally likely or
possible that the data may more closely reflect a different aspect of their identity.
It is important to note that although a major finding in this study was the push for Black
men to enter primary care, no participants were pursuing a career in primary care. Although
Faizon was pursuing internal medicine and Irvin was pursuing pediatrics, both expressed a
specific goal of pursuing subspecialty training. This lack of data is an important barrier to
generalizability of this finding. It is important to also acknowledge that this study does not

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illuminate why or how Black male medical students choose to pursue a career in primary care.
Future studies are needed to understand these points.
It is also important to acknowledge the lack of data about intersectionality of sexual
orientation and gender identity. Although the inclusion criteria were Black men in their third or
fourth year of an allopathic medical school, no trans-men were recruited for this study. Similarly,
although the author did not inquire about sexual orientation, no participants spontaneously self-
identified as having a sexual orientation other than heterosexual, and many participants described
their heterosexual relationships. Given the intersectionality of these identities, it is important to
note this lack of representation.
It is interesting to note that there was very little acknowledgment of the influence of
COVID-19 related barriers. Although this was not an area of interest a priori, given the enormity
of the pandemic and the adjustments to the clinical learning environment, it is interesting to note
that this did not come up. It is unclear what were the reasons for this, and it would be an
important area for further investigation.
Recommendations for Future Research
This qualitative study presents a variety of further avenues of inquiry. There were several
findings that were surprising to this investigator and that have not been commonly described in
the medical education literature. Chief among these findings is the push towards primary care.
There is a need for both qualitative and quantitative studies to not only understand these
phenomena at a greater depth, but to also understand the generalizability of these findings across
race, gender, and sexual orientation.
This study not only reinforced the important role of mentors, but also reinforced the
racialized nature of the subjects’ experience. Although this study described the subjects’

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experience with cross-racial from the Black male perspective, as the medical education
community works to increase the inclusiveness of the environment, it is also important to
understand the faculty/mentor perspective. A deeper qualitative and quantitative understanding
would be important to guide interventions to increase faculty capacity for mentorship.
The subjects’ experiences with OB/GYN and orthopedics were surprising. These findings
have not been well described in the literature. There is a clear need for quantitative studies to
understand the generalizability of these findings. Additionally, given the highly gendered nature
of both fields, there is need for further quantitative and qualitative studies to characterize both
the racialized and gendered nature and causes of these findings.
Finally, the positive perception of psychiatry has the potential to provide insight on how
specialties can promote an inclusive environment in all fields. While psychiatry, as a field, was a
positive deviant in terms of inclusivity, it is also likely that fields among racially hostile fields,
such as orthopedics and OB/GYN, also have specific programs that are also positive deviants
with regards to inclusivity. A qualitative study of positive deviant programs across a wide range
of fields would likely yield important lessons for all medical education.
Conclusion
As medical schools move to not only increase their diversity and realize the benefits of
diversity, there is also an increased need to address inclusivity and equity in the environment.
Although there is a role for quantitative measurements such as inclusion surveys, this study
underscores the importance and utility of understanding the experience of marginalized
populations. Centering on the perspective of marginalized persons not only reveals their
experience, but also paves the way towards an inclusive environment.

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As medical schools and the entirety of medical education embrace the principles of DEI,
we must be careful about how we conceive of and justify the focus on diversity. The medical
profession and the business of healthcare has a direct role in not only creating racial and
socioeconomic inequalities, but also a role in their persistence through inaction. Admitting
marginalized students in exchange for their fulfillment of racialized obligations is inherently
unfair and racist. As a profession, we need to move towards an environment where there is a
collective responsibility for not only creating an inclusive environment, but to address the myriad
of racial, social, and economic health inequities.

113
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Appendix A: Interview
Thank you again for agreeing to meet with me and giving me the opportunity to interview you.
As we discussed over email, the purpose of this study is to understand how Black and African
American males make their decisions about what specialties they choose to pursue. As you
know, Black males are not only severely underrepresented in medicine, but they are further
underrepresented in many medical and surgical specialties. Although there are many people who
are interested in addressing issues of diversity, equity, and inclusion in their fields, none of what
is known about how students choose their specialty has centered on the minority voice. By
conducting this research in a manner that centers on Black male voices, we are hoping to gain an
understanding of this process in a manner that centers on the Black male experience. The hope is
that doing this will influence the system in a manner that can better support Black males in their
decision making. In order to conduct this research, I will record then transcribe this interview.
All files will be stored in an encrypted folder on the researcher’s computer. Although we will be
using direct quotes in the publications, we will not use any that are easily identifiable. It is
important that you understand that your participation is voluntary. You are free to not answer any
questions and to stop your participation at any time without retribution.
Do you have any questions before we begin?
Do I have your consent to start the recording?

157
Interview Questions
What are the internal and external influences on African American/Black male medical students’
specialty selection?
• Tell me about what specialties you are thinking about pursuing.
• What guidance or advice have you received on choosing your specialty?
• Do you have any experience with mentors both inside and outside of medical school?
Can you tell me about that experience?
• Are there any fields that you have been discouraged from entering? How was this
conveyed to you?
• How have your peers (classmates, alumni) influenced your specialty interests?
• What has been your experience with the guidance and direction you have received
regarding specialty selection, especially with regards to being race-conscious
What are the critical experiences of Black male medical students in choosing a specialty?
• Are there any fields that you perceive or have experienced as being especially
discouraging or unwelcoming or racist towards Black men?
• What fields do you think that Black males are expected to go into?
• What do you see as the medical school’s message regarding selecting specialties?
How do African American/Black male medical students resolve conflicts between internal
beliefs and external expectations with regards to specialty selection?
• Are there any fields that you perceive or have experienced as being especially
welcoming or encouraging towards Black men?
• Is there a field you were thinking about pursuing but changed?
Can you tell me about what led to that decision?

158
What has been your experience with finding a mentor or someone to guide you through the
specialty selection process?
What experiences or interests prior to medical school play into your interests coming into
medical school?
What interests did you have coming into medical school?
What role did your pre-clinical performance, including your step 1 score, play into your decision
both positively or negatively?
What do you look for in a mentor?
Do you have any Black mentors?
Do you have any non-White mentors?
How is your relationship with the other students in your class?
What are some of the messages that you have heard surrounding the importance of diversity in
medicine? What is your perception of those messages?
What are the messages that you have gotten from your peers versus those from the medical
school vs mentors vs advisors?
Conclusion to the Interview
I want to thank you for your participation. I wanted to also see if you have any questions
or is there anything that we talked about that you would like to elaborate further. As I go through
the analysis of our interview, would it be OK if I recontacted you to make sure that my
interpretation of your answers matches your intentions?
Thank you again for your participation.

159
Appendix B: Recruiting Participants
Student doctors,
I wanted to reach out to recruit participants in my doctoral dissertation study seeking to
understand how Black male medical students make decisions about what specialty to pursue.
This study uses critical race theory as its conceptual model and hopes to uncover the role that
race and racism plays into that decision-making process in a manner that centers on the voices of
Black men and their authentic experiences.
This is a video briefly describing the study and the
rationale https://youtu.be/sgQcWwHThXE
Participation would involve an interview over zoom where I would ask you questions
about how you have conceived and approached your decision-making. Participants will receive a
$25 Amazon gift card as compensation for your time.
Please do not hesitate to contact me if you are interested in participating or have any
questions or concerns about the study.
Thank you for your consideration.

Abstract (if available)

Abstract Black men experience racialization in medicine stretching from underrepresentation, marginalization, to racial hostility. In contrast to national trends, they are more likely to pursue the lowest paying jobs and in the least prestigious fields. This study employed qualitative methodology through a critical race theory framework to understand the role of race and racism in how Black men choose their specialty. Sixteen Black male medical students were interviewed for this study. Participants described a variety of racialized experiences and forces that not only shaped their decisions, but narrowed their choices. In their exploration of fields, they found fields that were both racially welcoming and those that were specifically racially hostile. Similarly, participants described racialized barriers to both connecting with mentors and receiving adequate racially aware mentorship. While the official messaging to students was that they should pick the fields they liked, participants described how they were pushed towards primary care fields. This message was so ubiquitous that it created a sense of racial duty for participants. While participants were able to resist internalizing these messages, they served as a constant presence in their choices. This study not only revealed the racialized experiences, pressures, and barriers to their free choices, it identified multiple points of intervention to address the forces of systemic racism in Black men’s specialty choices.

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Asset Metadata

Creator Taira, Taku (author)

Core Title The role of race and racism in Black male medical students’ specialty selection process

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 02/06/2023

Defense Date 12/05/2022

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

Tag Black,Black male,CRT,DEI,Medical education,medical school,OAI-PMH Harvest,residency,UME,Urim

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Canny, Eric A. (committee member), Seli, Helena (committee member)

Creator Email taku.taira@gmail.com,takutair@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112724694

Unique identifier UC112724694

Identifier etd-TairaTaku-11468.pdf (filename)

Legacy Identifier etd-TairaTaku-11468

Document Type Dissertation

Format theses (aat)

Rights Taira, Taku

Internet Media Type application/pdf

Type texts

Source 20230206-usctheses-batch-1006 (batch), 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 author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

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

Repository Email cisadmin@lib.usc.edu