As doctors and nurses across the United States continue to gather outside hospitals and clinics to protest police brutality and racism as part of the White Coats for Black Lives movement, LaShyra Nolen, a first-year student at Harvard Medical School, says it's time to take medical schools to task over racism, too.
The fight for equality in medical education isn't new, says Nolen, the first black woman to serve as Harvard Medical School's student council president. But she's hopeful that the national conversation around racism in society will force hospitals and medical schools to address racism within their own institutions.
"It wasn't until over a week of riots that people started to pay attention," Nolen says. "We bring black med students to these institutions, and they fill quotas, and they make institutions look good. But we're not protecting them. We need to protect them."
Studies show that students of color and those who are LGBTQ are more likely than other classmates to experience mistreatment during their training. Research published earlier this year in JAMA Internal Medicine, for example, suggests that minority students are more likely to face discriminatory comments, public humiliation and inappropriate sexual advances during their medical education.
Nolen has been heartened by the outpouring of online and in-person activism she's seen, ranging from Twitter testimonials to opinion pieces in major medical journals. She's been involved in efforts at Harvard and nationally to combat racism in medical education.
But there is much work to be done, she says.
The JAMA Internal Medicine study of more than 27,500 medical students in 2016 and 2017 found that 38% of students nationwide from racial and ethnic groups that are under-represented in medicine — including students who are black, Latino or Native American — reported mistreatment. That's compared to only 24% of white students across the U.S. who said they had been mistreated during medical school.
The results raise questions, the study authors say, about racism in medical education and its implications for the persistently low numbers of people of color who become doctors.
"If these small disadvantages accrue throughout medical school, it could be contributing to keeping certain populations out of medicine," says Katherine Hill, the study's lead author and a medical student at Yale. "Discriminatory comments can have a negative impact — both on the people who are targeted, and on bystanders."
Hill and her team used a data set known as the Association of American Medical Colleges Graduation Questionnaire. It's a survey about medical school experiences that almost every medical student completes right before graduation, covering topics ranging from student debt to how prepared they feel they are to practice medicine. The data in Hill's study included responses from about 72 percent of all med school graduates in 2016 and 2017.
Mistreatment during training was a major focus of the survey. Students were asked if they had been publicly humiliated, for example, or been asked to perform sexual favors in exchange for good grades, or been subjected to offensive remarks or names.
More than 35% of the students responding to the survey said they had experienced some kind of mistreatment during medical school.
"It's almost part of the medical school culture that a faculty member may try to embarrass you or humiliate you," says Dr. Dowin Boatright, an assistant professor of emergency medicine at Yale and the study's senior author.
The roots of that bullying culture in medical training are complex, Boatright adds, but he guesses it often occurs in high-stress environments in the hospital, or because it's perceived as an accepted hazing ritual.
Previous research corroborates Boatright's observation that these kinds of experiences are common for students of all races, particularly during clinical training, when students are no longer in the classroom. During that clinical period, students are the least powerful members of a hierarchy, joining teams of medical residents and attending physicians, nurses, and other health care professionals as they care for patients.
What's new in his study, Boatright says, is just how much more likely minority students are to experience this harassment, bullying behavior and abuse.
Women and students who identified as lesbian, gay, bisexual, or transgender were also more likely to experience mistreatment, whatever their race or ethnic group. Above 40% of women reported that they experienced mistreatment, compared to about 25% of men. Similarly, about 43% of LGBTQ students reported an incident of mistreatment, while just over 23% of heterosexual students did.
Boatright and Hill both note that not only are minority students more likely to experience racist or bigoted incidents, they are also more likely to experience mistreatment in general — such as being humiliated in front of a team — even when the harassment doesn't seem specifically related to race or ethnicity.
Take the experience of Dr. Michael Mensah, who had to listen as one of his professors repeatedly used the N-word at work when Mensah was a medical student in 2015 at the University of California, San Francisco.
Mensah, who is now a psychiatry resident at the University of California, Los Angeles, says he and colleagues were sitting in a hospital workroom at the time, listening to music as they prepared to round on their patients. A song came on that used the expletive. To Mensah's shock — and to the shock of everyone else on his team — his supervisor casually repeated the expletive multiple times.
"I had a repugnant choice: swallow my lump of anger and sadness to preserve group harmony, or risk my grade and reputation by confronting my superior," he wrote in a 2017 essay in JAMA Internal Medicine about the incident.
More than five years later, the words still sting.
"If that person was willing to speak so frankly to us, and so rudely ... Imagine how that person treats their patients of color," Mensah tells NPR.
While he says he heard from many other students who experienced racism during training — physicians mocking non-white patients, peers telling their classmates of color they were accepted to medical school because of their race — some other people who read the essay dismissed his experience as a one-time incident.
Instead of questioning whether structural racism might be built into medical training, they dismissed that supervising physician as "only one bad apple," Mensah says.
"It really validates my personal experience, which is remarkable because of how isolating these experiences can be," he says. "It makes clear that I wasn't the only one to experience differential, unequal and discriminatory treatment. It helps me feel like what I went through wasn't my fault."
Mensah worries that the prevalence of mistreatment toward students of color, women, and LGBTQ students has another legacy: normalizing discrimination in health care, and ultimately affecting the way future doctors treat their patients.
"There's a direct link between this abuse and how some of our health care disparities play out," he says.
Now, Mensah is focusing much of his energy on addressing racism in health care institutions. He recently wrote, along with several co-authors, an op-ed in Scientific American about how the misuse of medical language in George Floyd's initial autopsy report overemphasized the role of coronary artery disease and hypertension in his death.
Mensah also spoke at a rally this month in Los Angeles sponsored by White Coats for Black Lives. But because there are still such persistently low numbers of black people working in medicine, Mensah found himself addressing a sea of white faces.
"I was the only black male there, unfortunately," he says.
Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.