a qualitative study of the - NCBI

A QUALITATIVE STUDY OF THE EXPERIENCES OF ONE GROUP OF AFRICAN AMERICANS IN PURSUIT OF A CAREER IN ACADEMIC MEDICINE Deborah 0. Erwin, PhD, Ronda S. Henry-Tillman, MD, and Billy R. Thomas, MD Arkansas

Recent reports demonstrate that medical school enrollment of minority students has continuously declined over the past several years and underrepresented minorities (URMs) continue to account for a disproportionately low percentage (less than 4%) of full-time academic faculty at medical schools in the United States. This article reports on a qualitative research project to examine the sociocultural experiences that influenced one group of minority physicians pursuing an academic medical career. Nine African American faculty, one resident, and one fellow from a Southern medical school of 574 full-time clinical and basic faculty completed 25 open-ended questions on a structured, qualitative interview plus background demographics. These nine faculty represented 82% (N = I 1) of the total number of African American clinical and basic scientist faculty on campus at the end of the 1999 academic year. The narrative interviews describe key decision points, environmental and economic influences, and cultural experiences that affected faculty career choices and illustrate the real-life experiences of current minority faculty and scientists. These narratives contain significant messages for addressing policy on school campuses to improve the opportunities and likelihood of increasing the proportion of minority physicians and scientists. (J Natl Med Assoc. 2002;94:802-812.)

Key words: minority recruitment * clinical training * African American

physicians INTRODUCTION Medical schools and health care institutions are incorporating cultural diversity training, © 2002. From the Department of Surgery, Arkansas Cancer Research Center at the University of Arkansas for Medical Sciences, Department of Surgery, Arkansas Cancer Research Center at the University of Arkansas for Medical Sciences, and the University of Arkansas for Medical Sciences, Office of Minority Affairs. For more information, phone (501) 686-8801, fax (501) 6866479, or send e-mail to [email protected]. 802

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evaluations, teleconferences, and committees into curricula, employee in-services, and employee assistance programs at an ever-expanding rate. The term "culture" is no longer just within the purview of anthropology. However, many of these efforts are aimed at improving the diversity of non-faculty staff and patient services. Currently, affirmative action programs and the recruitment of minorities into professional medical training are the lowest they have been in over a decade in spite of counter efforts by the National Institutes of Health, Robert Wood Johnson Foundation, and the Health Resources and Services Administration.' These VOL. 94, NO. 9, SEPTEMBER 2002

MINORITIES PURSUING MEDICAL CAREERS

and other efforts have increased funding and programming to enhance faculty development and research/training opportunities for minority scientists and physicians. However, recent reports demonstrate that medical school enrollment of minority students has actually declined continuously over the past several years.2-4 Underrepresented minorities (URMs), including African Americans, Mexican Americans, Puerto Ricans, American Indians, and Alaska Natives, continue to account for a disproportionately low percentage (less than 4%) of full-time academic faculty at medical schools in the United States.5' " Moreover, compared to their White colleagues, minority assistant and associate professors in medical schools experience significantly lower rates of promotion as evidenced by a recent study of cohorts hired from 1980-1989."i These data regarding the limited number of URMs in medical profession schools and in positions to mentor students are especially disturbing as we recognize the need for "cultural competence and racial/ethnic role models. . .for effectively performing clinical research and providing quality health care for diverse populations.' In a landmark article published in the Journal of the American Medical Association by Palepu and colleagues on minority faculty being less likely than white faculty to hold senior academic rank, the authors suggest that "qualitative studies may have a role in identifying factors that minority faculty perceive as barriers to their advancement and in suggesting effective interventions"7. This article reports on a qualitative study to examine the perceived barriers, sociocultural issues, and career experiences that influenced one group of minority physicians pursuing an academic medical career in order to better understand this process. The narratives and experiences from this study have been organized into four domains: 1) Career Development: Early Influences and Challenges; 2) Working the System; 3) Professional Training Experiences; and 4) Student/Faculty Development. These data document the need JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

to address policy on our campuses to improve the opportunities and likelihood of increasing the proportion of minority physicians and scientists.

METHODS Nine African American faculty, one resident, and one fellow agreed to complete structured, open-ended, qualitative interviews for a total of 11 interviews. All are from a Southern medical school of 574 full-time clinical and basic faculty. These nine faculty represented 82% (N = 11) of the total number of African American clinical and basic scientist faculty on campus at the end of the 1999 academic year. Two faculty were not interviewed because of time constraints, and the movement to new faculty positions out of state. The two residents and fellows represent a smaller sample (22%) of nine African American residents and fellows, and were included in the interview sample in order to increase the age range of respondents. The author felt it was important to provide data on experiences from more recent graduates. All of the African American faculty members, residents or fellows were contacted by telephone, e-mail, or in-person, by the author to request an estimated one and a half hours of their time to participate in the study. There were 25 structured, open-ended questions in the interview, plus background demographics. These interviews were intended to accomplish several goals: 1) to obtain information on key

decision points, environmental and economic influences, and cultural experiences that affected faculty career choices, 2) to provide qualitative data necessary for developing future interventions for minority student and faculty recruitment on campus, and 3) to illustrate the real-life experiences of current minority faculty and scientists. Table 1 lists the structured inter-

view question topics. Answers to questions were recorded in writing during the interview. The interviews took place in various locations including the author's office, a hotel, and local restaurants off campus. These interview sessions lasted from VOL. 94, NO. 9, SEPTEMBER 2002

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Table 1. Structured Interview Question Topics BACKGROUND 1. Description of family of origin - who you grew up with, where they are now? 2. What work did your parent(s) do while you were growing up? What affect did their occupation have on your career decisions? 3. What role does your family's (parents, siblings, other) residence make on your career choices? Has that changed over time? ACADEMIC DEVELOPMENT

4. Overview of your elementary, middle school and high school academic map. 5. Where did you attend college? Why? What was the ethnicity of the school? faculty? 6. Where and why did you go to medical school? What relationship did personal friends and family have on this

decision?

7. Why did you select the medical school you attended? 8. Ethnicity of the students? The faculty? How would you characterize your personal experiences there? 9. Residency selection process and experiences. PERSONAL CONTACTS

1 0. 1 1. 12. 13.

Mentors (other than family) earlier in your life? Do you have a mentor(s) now? Why? or why not? How have these relationships affected your career choices? Do you consider yourself as a mentor for anyone now?

CURRENT INSTITUTIONAL AFFILITATION

14. 15. 16. 1 7.

18. 19. 20. 21. 22.

Why did you interview for your current position at ? Did you have plans to come to earlier in your career planning? How long have you been at ? Where are other close friends of yours from medical school? (particularly other African American/Latino colleagues?) What helped you in your career planning? What were some of the major obstacles you encountered in your career planning and progress? What would have helped you more in your career planning? The single most important factor that brought you to ? To your current department? to effectively increase minority student/resident/faculty representation? Suggestions you have for Recruitment?

PROFESSIONAL RELATIONS

23. From your knowledge and experiences, how do you think the African American/Latino physicians in private ? practice relate to 24. Do you think this is different from the Caucasian physicians? Why? 25. What do you think would improve relations with these physicians? one hour to three and a half hours. Approval for the study was obtained by the Human Research Advisory Committee on campus and all participants signed written informed consent forms. The transcribed responses resulted in a text of over 21,500 words. Thematic analysis of these interviews was used by the author to examine the similarity and differences in experiences and perceptions of respondents. Thematic analysis is an ethnographic tool to organize a large amount of textual data in order to discover patterns, themes and linkages that bring meaning to the experiences and narratives. This is accom804


plished by reviewing all text, coding and ordering the contents, and evaluating all of the codes for consensus and variation. Consensus texts are then grouped into domains that describe, explain or elucidate behaviors, experiences or outcomes.8 This analysis resulted in the four domains described, and the selection of specific narratives and quotes that were representative of the majority of respondents. Various examples were chosen to illustrate exemplary positions. Some narratives are condensed in order to provide a summary of the responses. A draft and final version of this manuscript were circulated to the respondents to VOL. 94, NO. 9, SEPTEMBER 2002


Table 2. Respondents by Ten-Year Age Cohort Age 20-30 30-40 40-50 50+

TotaI

Number 1 5 3 2

Percentage 8% 42% 33% 17%

11

100%

Table 3. Faculty Status of African Americans Interviewed and Total Faculty Status

Assistant Professor Associate Professor Professor Chair

African American 5 (45%)* 2 (1 8%) 1 (9%) 1 (9%)

Total**

verify accuracy of the quotes and thematic analysis. In order to maintain as much anonymity as possible with such a small population of minority faculty, fellows, and residents, quotes are not identified by gender, age, or professional specialty or expertise.

RESULTS

Demographics And Backgrounds of the Participants The ages of faculty interviewed ranged from 29 to 51 years of age. Table 2 shows the age cohorts of respondents. The average age of the full-time faculty respondent is 42.6 years with a median of 45. This is slightly younger than the average age of all full-time faculty at the institution (47 years) (Source, Human Resources office). Six of the respondents are female (55%) and five are male (45%). This is significantly different than the campus distribution, which is 73.9% male (424) as compared to only 26.1% (150) female. The gender distribution of African American medical school students on this campus mirrors the minority faculty distribution of this sample, with a higher proportion of female students. The participants are distributed in eight different departments. Excluding the residents and fellows, they have been on staff at the institution from 2 to 18 years, averaging 10.4 years. The African American faculty status distribution and that for the entire faculty is shown in Table 3. Seven (64%) of the participants were born or lived a significant portion of their childhood in the home state of the medical school where they are now employed. Of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

9

All Faculty 256 (45%) 167 (29%) 126 (22%) 25 (4%) 574

*Percentages reflect the proportion of those interviewed in comparison to all African American faculty on campus (N = 11). **Two individuals interviewed were resident or fellow status.

these seven, only one is currently tenured. Of the four participants who were born in other states, three are tenured. Therefore, a total of five (56%) of the nine full-time faculty are not tentured, compared to 45% of the entire faculty at the school. Six (55%) of the respondents went to this institution for undergraduate medical school training. Of the remaining five, three went to other state medical schools and two went to private, historically black medical schools (HBMS). None of the participants' parents were physicians.

Career Development:

Early Influences and Challenges Six of the respondents specifically stated that early exposure to science and African Americans in medicine and science positively influenced their decision to pursue a scientific career. A striking example of the influence of a single powerful individual to influence the development of a student is exemplified below from an experience in the eighth grade of a magnet junior high school: My mother sent me to [the magnet Jr. High]. It started an hour earlier than all the other junior highs so I had to be there at 7 am. We had a speaker to talk to us for an hour evey morning about what they did and what you can do with a science degree. Dr. Elders

[Joycelyn Elders, MD, former Surgeon General, at this time was a practicing physician] came one day and told us about being a doctor. She showed us photos of VOL. 94, NO. 9, SEPTEMBER 2002

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her in the clinic and talked about how much fun it was and how much she loved it. I wanted to be a beautician until then. That's the birthday [131h] that I wanted a microscope. These physicians and basic scientists reflect a wide variety of social and economic backgrounds, which is representational of both the faculty in general and the minority population they serve. Not uncharacteristically, the majority come from families of limited incomes, but all reflect a value structure that encourages education, a strong work ethic, and service. Being in a farming area, you learn that you have to work to achieve. . .And you were expected to work through whatever system zvas there. Minorities, in general, were judged by how much work you could do in the field. Men would say things like 'I can pick 400 pounds of cotton.' That really meant something to people. Especially minorities. Everybody worked. Some early experiences, especially in the school systems, demonstrate significant challenges for the minority faculty. These experiences were undoubtedly different from those experienced by white counterparts then or now. Amazingly, many of these experiences are similar for these minority scientists whether they were in the Northeast, West, or the South; rural or urban; or whether they are 51 or 30 years old. All of the respondents told of some experiences related to discrimination or racism. ... Thefirst time that I thought it wasn 't okay was in 1965 when two other black girls and I decided we would go to the white high school. I was thefirst black male to finish at the school. All of a sudden we were flunking Trig. We had been the smartest kids at our black high school and never had major problems with anything and now we were flunking out of Trig. This was a level of math that we hadn't been exposed to. We lacked information. ... We didn't have a good academic background and I was told this in college. We had textbooks and librar9 books that were handme-downs from the white school and they were out of date before we got them. I wanted to get out of [Southern state] because of thefear, racism, limitations, ignorance, and lack of opportunity. I went to [private college in the Mid806


west] because my brother went there. . It was thefirst time I'd ever met a liberal white person and I thought I'd gone to heaven. These were the first whites I'd ever met who weren't cruel. I left public schools in high school. I went to a private Catholic high school. I played Jbotball in the ninth grade. In my class, there were six black students. We were the first black students in the school. T'he faculty in high school was all white. It was a difficult experience for people. My mother was thrilled I was going there because it was a very good education. It put me in a competitive/survival mode each day. It helped push me. It was very competitive aca-

demically." Even for younger professional minorities who grow up in relatively affluent families with financial and social opportunities to achieve that equal to their Caucasian colleagues, there are challenges: Desegregation was all over when I got into school. I was always separated out from the other black kids and 'accelerated' with white kids. I felt different. I was not white enough for my white friends, but not black enough for the black kids.

Working the System In preparing for a professional career in medicine or basic sciences, many of the respondents discussed difficulties they had in negotiating the "system," not knowing how to go about working toward a career in medicine, or lack of confidence in their abilities to achieve this goal. I didn't know what it meant to prepare, or go through the process - to 'play the game. 'Nobody [other African American students] knew about it. Advisors at majority schools discouraged you or would tell me not to apply because I was African American. So, we'd just believe these authority figures when they would tell us we weren't good enough. There was only one Black physician in our community. That makes you think, is this really possible for me? If there aren 't many there my chances are pretty slim or there'd be more. I wanted to go where the

opportunity was. Likewise, as students, the respondents relied upon and looked for assistance from school VOL. 94, NO. 9, SEPTEMBER 2002


counselors and instructors at their colleges and universities for guidance and mentoring in achieving their goals. The counseling they received ranged from supportive and helpful.. .telling me, 'You can do that if you want it. " to extremely biased and destructive: We were required and told we had to join the pre-med club-the Cadaver Club. So I did. And we thought we were doing everything we needed to do. But the advising we received was not good. [Her pre-med advisor] recommended I take remedial reading as a freshman. He told me I had to take it. As a freshman, I didn't know what this was, and I didn't even realize it was a remedial reading course until several weeks into the course and the course director asked me why I was in this course. I had been told by my advisor that it was a 'required reading course. ' I thought evern freshman took the course... So I just finished up) the course and helped the director with other students. Almost all of the students were African American. I couldn't believe it when I discovered what the course really was. My mother was furious! ...But my last semester, as I'm getting ready to graduate, I found out it didn't count toward ny credits to graduate! I was allowed to 'walk' at graduation, but had to take another course in English in summer school, after I should have graduated, to be able to graduate. It was a waste.

Professional Training Experiences Once into the medical school and residency training programns, the respondents reported varied social and educational experiences, as might be expected. There were some significant differences in perspective between those students who were minorities at their medical schools versus those who attended historically black medical schools (HBMS). The minorities trained at HBMS reported more support and fewer social issues. In fact, being within a mi-

nority setting during their training experiences appears to have provided an opportunity for the individual to concentrate more on the science and the work, and less on the social factors. I went to [HBMS]. The students were 90:10 African American to white. The faculty was about JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

50:50 then, probably 60:40 now. It was a small five-year program with only 16 students. The curiculum was different. All 16 of us graduated. I really liked [the school]. Going there made it easier,for me later. I got to see that the relationships with nurses and attendees andfaculty are the same with eveiyone everywhere. It's just medical school and doctors and nurses, not race-related like students think nowti, here. This program at [HBMS] was much less stressful. Many white students [at his HBMS/ were children offormer graduates. I had never really been in, that situation before, to be part of the majority. There was no difference in the stru,ggle of medical school- the volume of work, intensity of the schedule- than what we have here. You did see some things that you don 't see here. Retired professors that would just show up to help students in the anatomy lab. We had a former chair of anatomy come by and help us. In the case of the majority of respondents who attended medical and graduiate schools and residency programs where they were in the ethnic minority, there were significant social situations that demonstrated perceived/real issues of justice, emotional stress, and socialization as it related to their being African Amierican.

Residency was a real effort. The program was not real fair for minorities. It wasn't user-friendly. 7'here are just thinTgs that you need to know and do that aren't easy for minority students because we don't socialize with the [attendings and faculty]not out eating dinner together or playing golf, etc. There were 150 students in my class, 13 were black, five of the blacks graduated. It was just hard. It was hard to stay focused. I had to put extra energy into the work. People were looking, peop5le were watching. The assumption was, 'You're dumb.' You have to maximize everything. For example, a white boy goes into class to take a test and he just has to worry and concentrate on the test. Every time a black boy goes into the class he has to try hard to stacy focused on the work, on the content, because he's worming about what the professor thinks of him, what the other students think of him, whether or not he has on the right clothes, or is acting the rigght way, or what his mother will do if he doesn't do well on this test, etc. VOL. 94, NO. 9, SEPTEMBER 2002

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There's just a lot of garbage that you end up fighting off and trying to spend all your energy beingfocused. I knew they didn't have any other minority residents and I was thefirst or one of the first minority women there. When I moved into my rental patio home, a white neighbor came over and brought some bell peppers to me. She said, 'I heard there was a black woman doctor moving in and Ijust wanted to see for myself 'I didn't realize I was moving into the white side of town. In fact, a woman at my church asked me if I thoutght I was too good to live with them in the black part of town. As in any professional career, mentors, in the form of professors, practicing physicians, and even other students often provided needed support and encouragement to these physicians and scientists. These mentors were often other African American role models, but not necessarily. My advisor.., only scheduled one science course per semester. And later, all of the good information we got was from graduating seniors. There was one student who helped us change our schedule. He'd look at what our advisor gave us and tell us 'Man, this isn't what you should take. . .' then he and others would tell us which courses to take together and what zwe needed and didn't need. My advisor had me taking all kinds of courses that wouldn't really help or prepare me for med school. Stuff like earth sciences or geology. The seniors told me to double up and take more sciences and biological sciences. When I'd take the reivised schedules to my advisor to sign he's say, 'You 're settingyourself upforfailure. " But he'd never congratulate me or say anything when I was able to pull it off and make A's in the two sciences. . . He [the pre-med advisor] had me on a plan that would have taken me six years to graduate. I did more than I had to, and did what I thought he wanted. Then he still didn't give me a good reference. There were no black faculty and few black professionals in general. I had strong black male role models in my neighborhood. This was very important for me, especially with my dad leaving home. The whole neighborhood was like my mentor. .. .They started an Explorer Post to keep the older kids interested. It was co-ed and career oriented which helped. It 808


had a medical theme because the post advisor was an x-ray tech. He had a strong influence on my life. From the interviews with these professionals, their experiences often describe a dialectic between encouragement and challenge. Almost every medical professional or basic scientist that has experienced graduate student training would agree that they felt many times that they would not be able to achieve their goal, or wouldn't have been as successful without the support and encouragement of certain people. However, the dialectic in the cases of these minority professionals often incorporate what may be termed "survival" versus "great possibilities." Many times, the challenges were directly related to characteristics that the individual had no control over and could not change their ethnic background. On the other side, as opportunities to achieve were presented, and the possibilities were perceived as attainable, this strengthened the individual's desire and confidence in achieving their professional goals. Over time, this growing confidence allows the individual to discount and manage the ethnic "st`rvival" challenges somewhat. In addition, it is absolutely essential that the "possibilities" be revealed early enough in a person's life, that they are able to aim their lives in a professional direction. Six of the 11 respondents listed exposure to science and African American role models in medicine as the number one item to help increase minorities in the sciences. Several interviews speak to this dialectic. The biggest obstacle was the idea of not knowing how to pursue a career... I had a complete lack of information and knew nothing about how to work the system. I needed to have more information available. . . My only memory of visitors to my school as a kid were at assemblies-having nuns hold singalongs-religious things. These were the only people from the outside at our schools. We needed more outside influences- someone to tell us what we could do. As a 15-year-old, I participated in a Presbyterian church program called REA CH. The head of the VOL. 94, NO. 9, SEPTEMBER 2002


program allowed me to get acquainted with individuals outside of my limited community - to see other experiences. I was from the lowest SES class, and it was good to interact with students and adults from upper and middle classes. It gave me a different view of life..Exposure to things - that's what has the greatest impact on possibilities in my life. Seeing my father as a laborer, my mother doing clerical work; when Igot a job as a bus driver, I thought I was really doing something and so did my community. I work with young people now because I realize they just don't know what their potential is, and it's important to let them know the possibilities. People seem amazed to see young black professionals here [Southern state]. When I go to talk with applicants to medical school and students, they seem to think, 'You mean I don't have to be a floor manager at Dillards or work at McDonalds all my life?' I was thinking maybe of tiying to go to med school, knowing in the back of my mind, the chances were slim. I was keeping my options open for other things to do to fall back on. I went to [HBMS]. .. . saw photos of black doctors from hundreds of years hung on the wall. I'd look around the hospital and I wasn't in survival mode anymore. I was in 'be the best you can be' situation. It was a different environment to me-in a positive, nurturing environment. It was very appealing to be the best. The dean is even black! My possibilities were unlimited.

Student/Faculty Development Finally, when asked about how to build upon their own experiences to create more "possibilities" and increase the chances that more minority students will select a professional career in medicine and science, the respondents had several suggestions. They also had comments regarding the social and medical justification and need to increase institutional and administrative support for more African Americans to be trained to be part of the medical sciences process. Ten of the 11 respondents expressed the need for institutional changes as the number one issue to address to increase the recruitment and retention of minority medical and basic science students. In addition, five responJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

dents mentioned the need to counter the antiaffirmative action perception of the institution. Minority students can go anywhere. We don't treat them like that. We haven't looked at faculty recruitment and retention. Nothing is in place for [minority] faculty to do to get together. We need something like the 'affinity groups'. The pool of 'qualified' individuals [for med school and faculty] is very small. And kind of like the stock market, the value should be greaterfor those qualified students in the pool. This is recognized by some institutions and a student is offered more to go somewhere else. Notjust more money, but support, as well. Efforts should be focused on the future, not the present. We need to increase the size of the qualified pool to enter programs here.... We're becoming more diverse as a population, so adding diversity in the students and faculty will improve the process. Numbers aren't important for numbers' sake. We need more interaction, more information that this is good. ...Blacks- on our campus, they are cleaning the floors-and the people in white coats are white. This is not a good comfort level when people interview here. We need to advertise differently and do things more unconventionally .... It's an 'us v. the bureaucracy' kind of feeling. The minority physicians [in the community] don't feel respected [either]. " Regarding recruitment of residents, I, as well as [African American resident] had a direct influence on the recent recruitment of an African American female medical student for our residency program. She had equivalent or better grades and recommendations but was far down on the match list. In fact, she had higher grades and performed better on in-services than some of the white males we were considering. I was an advocate for her and we moved her up on the residency placement. She matched with us." We need more minority faculty to teach and be role models. I'm sure the minority patients are happy when they have an African American doctor they can relate to better. Many of these patients don't really understand what's going on. They need to trust the doctor and are glad to see a doctor like them. Many minority patients have been taken advantage of, as an intern, I saw this. They are happy to see people like themselves. Having more minority physicians to treat VOL. 94, NO. 9, SEPTEMBER 2002

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patients may change the way patients are doing thing, like compliance. Having a doctor they can relate to is important for them to understand their treatment. ... [the institution] needs to put minorities into significant Positions in administration and faculty. Key positions, so that everyone you see who's black is not just sweeping the floors. 7hen recruits will think, 'Someone believes in him (black doctor, administrator), so it must be okay here. It must be okay to be a part of this group. " They [minority physicians in the community] relate poorly because they don't see themselves when they see [the academic medical center]. Nothing about themselves is reflected at [the academic medical center]. It's an alien beast. Some things I've experienced have indicated that race wvas an issue. It 'sjust one ofthose things you just have to deal zith. You have to work on overcoming your own reactions. They told us at [HBMS/'You'll be dealing with race at some level all of your careers. You can 't settle for being aver(age. You have to be 10 times better to get the same respect.'Txhey told us from a long time ago, medicine is a good ol' boy

system.

DISCUSSION These data provide an intimate examination of experiences from 11 minority professionals in the South. The generalizability of these data are limited by the fact that it was a limited sample of non-randomly-selected participants. However, as this is the nature of qualitative data, it is intended to provide a rich source of representative experiences that illuminate the specific perceptions, challenges, and issues that may be influencing the disproportionately low percentage of minorities in full-time academic faculty positions. In addition, the depth of the interviews and the diversity of age, geographic origin, and class background of the participants strengthen the applicability of this study to other minorities in academic medicine. A second source of potential bias in this study was the fact that the interviews were not taped and transcribed, but were recorded as a written record during the interview. This was ad810


dressed by having the participants review both the draft and final version of the manuscript. Ethnicity is not the only issue related to diversity. Certainly, these qualitative data demonstrate significant class and economic issues that acted both as positive and negative influences on the careers of the professionals in this study. Likewise, the perceptions and experiences of these faculty provide rich material for improving our medical school systems to create a better environmnent for education, research and service. They also demonstrate quite clearly that students and faculty may still be treated differently because of the color of their skin. In a recent article in the Amer-ican Journal of Public Health, Camara Phyllis Jones, MD, MPH, PhD, from the Harvard School of Public Health, provides a theoretical framework for examining racism.9 Jones argues the importance of examining the effects of racism in causing race-associated differences in health outcomes. Jones' framnework, as well as the qualitative data presented in the currenit research encourages us to examine the possible effects of racism in causing race-associated differences in our minority student and faculty recruitment, development, and retention. She defines three levels of understanding: 1) Institutionalized Racism is defined as "differential access to the goods, services, and opportunities of society by race.. .It is stru-ctural, having been codified in our institutions of custom, practice and law... Manifests itself in material conditions and in access to power." "With regard to access to power, examples include differential access to information, resources, and voice (representation in government) ."7 This construct was demonstrated in these interviews by specific educational adversities and community limitations including a lack of knowledge of how to "work the system." 2) Personally mediated racism is defined as "prejudice and discrimination, where prejudice means differential assumnptions VOL. 94, NO. 9, SEPTEMBER 2002


about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race." "...can be intentional as well as unintentional .......... manifests as a lack of respect, suspicion, devaluation, scapegoating, and dehumanization."7 This was exemplified in the current study by the remedial reading experience. 3) Internalized racism is defined as "acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. It is characterized by their not believing in others who look like them, and not believing in themselves. It involves accepting limitations to one's own full humanity, including one's spectrum of dreams, one's right to self- determination, and one's range of allowable self expression. It manifests as an embracing of 'whiteness,' self-devaluation, resignation, helplessness, and hopelessness."7 and was illustrated by many respondents' questions of themselves, "Can I do this?" or comments like, "Blacks- on our campus, they are cleaning the floors-and the people in white coats are white."

Jones suggests that "institutionalized rac-

ism," is the most fundamental, and if addressed, the other levels of racism may cure themselves. The results of the current study suggest that the current administration of medical schools in the US take a careful, critical look at the internal systems and processes that may be negatively influencing the diversity on our campuses. It is then our responsibility to take positive actions and measures to counter any signs of institutionalized racism on our own campuses, as well as at the undergraduate universities from which we recruit. It's difficult to ascertain exactly what factors, presented at what time within the life of an individual are most likely to positively influence JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

a career choice. Within the minority culture, this process may be even more complicated. The experiences in this study suggest four areas in which interventions might be initiated to address the challenge of minority recruitment: 1) Career development during the earliest years of education-focused attention for minority students to be exposed to science and medicine; and most importantly, demonstrations that these skills and professions are within their own reach. 2) Mentoring and opportunities to learn to "work the system" -students need strong encouragement and efforts by medical schools and universities to provide equal treatment for all pre-medical school students, and provide specific guidance and examples regarding processes of course selection, application and interview processes. 3) Examining ways to provide more mentors and positive professional training experiences for minorities free of latent and direct discrimination; and 4) Increased attention to specific student and faculty development programs for minorities to assure equal respect and internal cohesiveness for all faculty and students, not just the majority groups. With the exception of early educational influences (e.g., speakers, school programs, summer programs, additional training, preparation, and scholarship programs), many of the early, pre-college influences are outside the direct scope of a university medical school to influence. However, how we conduct and encourage the recruitment and development of minority students and faculty once they reach our campus is very much within our venue to improve. There is a need to collaborate with local public schools to provide students with a good look at the possibilities, and what is required to obtain those goals. And there is a need to provide physical, cultural, financial, and psychological resources and support to improve processes on campus and move our institution to the top of the cultural competency ladder. Recognizing the need and valuing the process is the first step. VOL. 94, NO. 9, SEPTEMBER 2002

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AKNOWLEDGEMENT This research was funded by the National Instittutes of Health/National Cancer Institute Special PopuLlationls Network cooperative agreement 1 UO1 CA86081, Arkanisas Special Populations Access Networ-k project.

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