Marcella Nunez-Smith

Impact of race on the professional lives of physicians of African descent.

Diversifying the physician workforce is a national priority (1). However, despite efforts to increase the numbers of minority physicians (26), people of African descent represent only 2% to 3% of practicing physicians in the United States (7). Furthermore, this proportion has not changed substantially during the past 30 years (1, 8). Understanding how race influences the work experiences of physicians of African descent is fundamental to developing effective strategies to recruit and retain a diverse physician workforce. Evidence indicates that physicians of African descent face considerable challenges because of their race. Most minority physicians report that they have experienced racial or ethnic discrimination at work (912), and rates of reported racial discrimination are highest among physicians of African descent (10, 11). Studies of physicians in academic medicine show that medical school faculty of African descent have lower job satisfaction (11, 13) and are promoted less frequently (14, 15) than their nonminority counterparts who have similar productivity and similar academic accomplishments. Although this evidence documents the substantial prevalence of race-related challenges for physicians, qualitative information to understand how physicians of African descent experience race in the workplace is lacking. The design of interventions to successfully attract, integrate, and support a diverse workforce depends on a clear understanding of the role of race in the professional lives of physicians. Therefore, we sought to characterize these experiences through in-depth interviews with physicians of African descent practicing in academic and nonacademic settings and across a range of clinical specialties. We used qualitative data analysis techniques to identify the unifying and recurrent themes that show how race shapes the work experiences of physicians of African descent. Methods Study Design and Sample We conducted a qualitative study by using in-depth interviews with 25 physicians who identified themselves as being of African descent and who practiced in 1 of the 6 New England states. People of African descent include Africans and African Americans and those from other regions of the African diaspora, such as African Caribbeans. We did not interview physicians of other races because we only studied how physicians of African descent experience race at work. We chose a qualitative approach to explore a complex and potentially sensitive topic involving social and cultural interactions that are difficult to measure quantitatively (16, 17). On the basis of principles of grounded qualitative research, we aimed to generate hypotheses from the data as opposed to testing prespecified hypotheses (1620). We recruited an information-rich and purposeful sample (16, 17) of physicians of African descent from the 6 New England states. We excluded physicians in training. We identified potential participants from the membership roster of the New England Medical Society (an organization of minority physicians); the Web-based African American physician locator, which uses membership data from the National Medical Association; community-based organizations; and regional academic institutions. We randomly selected physicians from among those who responded to an invitation to participate within the first 2 weeks. In addition, using the snowball technique (16, 17), we asked study participants to provide names of other physicians of African descent in the region. All invited physicians agreed to participate. We interviewed practicing physicians until no new themes emerged from successive interviews, that is, until thematic saturation was achieved. The research protocol was approved by the Human Investigation Committee of the Yale University School of Medicine, New Haven, Connecticut. We obtained verbal informed consent from participants. Data Collection One of the researchers conducted in-person, in-depth interviews (21). Interviews were racially concordant and consisted of the interviewer and an individual participant. The average length of the recorded interview was 40 minutes. Professional transcriptionists transcribed interviews, and the interviewer reviewed the transcriptions to ensure accuracy. Interviews (Figure) began with a broad question: How do you think race influences your experiences at work? Specific questions addressed negative and positive work experiences attributed to race and the influence of race on the physicians career trajectories. Probes were used to encourage participants to clarify and elaborate on their statements as necessary. Figure. Standard interview guide. Statistical Analysis In the first stage of analysis, codes were created and defined as concepts that emerged from the data in an inductive fashion (21, 22). The coding team independently coded transcripts line by line and, as needed, met as a group to reach consensus. Using the constant comparative method of qualitative analysis (21, 22), we compared coded text to identify novel themes and expand existing themes, refining the codes as appropriate until we reached a final coding structure that comprehensively defined all codes (22, 23). Using this final coding structure, the researchers independently coded 3 previously uncoded transcripts. The calculated intercoder agreement was 80%, which is considered acceptable by qualitative research standards (24). One researcher then used the final code structure to recode all transcripts. We used qualitative analysis software (ATLAS.ti 5.0, Scientific Software Development, Berlin, Germany) to facilitate data organization and retrieval (25). As recommended by experts in qualitative analysis (23), participants reviewed a summary of the data and endorsed the content of the themes after the analysis was complete. Role of the Funding Sources The funding sources had no role in the design, analysis, or reporting of the study or in the design to submit the manuscript for publication. Results Physician participants represented a range of practice settings, specialties, and ages (Table). Five recurrent themes characterized how physicians of African descent experienced race in the health care workplace: 1) awareness of race permeates the experience of physicians of African descent in the health care workplace; 2) race-related experiences shape interpersonal interactions and define the institutional climate; 3) responses to perceived racism at work vary along a spectrum from minimization to confrontation; 4) the health care workplace is often silent on issues of race; and 5) these experiences can result in what we term racial fatigue, with personal and professional consequences for physicians. We provide verbatim quotations to illustrate each theme. Table. Characteristics of the 25 Study Participants* Awareness of Race Permeates the Experience of Physicians of African Descent in the Health Care Workplace All participants described race as pervading their identity and experiences in the health care workplace. Physicians offered several examples of how race often influenced their professional experiences. A general surgeon at an academic institution commented on his perception of how he is viewed by others at work: I think race permeates every aspect of my job; so when I walk onto a ward or on the floor, Im a black guy before Im the doctor. Im still a black guy before Im the guy in charge, before Im the attending of record, so that permeates everything. Participants also described the importance of race in influencing their self-view in the workplace. For some physicians, the influence of race on self-view was shaped by the participants country of origin. A general internist at an academic institution who is from the United States reflected: I am your classic African American. What I mean by that is that I think about race all the time. At least 50 times a day. I wouldnt say race has influenced me. It defines me. It defines what I do. [It defines] everything. In contrast, a physician practicing family medicine at an academic institution who immigrated to the United States as an undergraduate student stated: Race influences the personalities of Americans much more deeply than for Africans or other people not born in this country. As an African, my primary mode of identification is not race. Still, most people [in this country] see me and for them its race. [S]o it definitely affects what I do. Its probably the most important thing. Regardless of where they were from, participants reported constant awareness of their racial minority status in the workplace. However, physicians sometimes tried to take the focus off of race in the workplace. An internal medicine subspecialist working at a hospital-based practice reflected: Growing up as I did in this country, however, I am perpetually aware of race with every individual that I meet, my cofaculty, my patients, the other health care workers here, but I think I have tried to take an approach that to whatever extent possible, I try to take race out of the equation. Regardless of whether participants focused on the influence of race at work, they reflected on the intersection of authority and race in their work lives. A pediatrician at an academic institution said the following: It is hard being a physician of color because you have the issue of race and the issue of power. When you are a physician, you have a power position that other people dont have, whether they are of the same race or different race or whatever. So, sometimes it is tricky. Are you annoyed that I am in the position that I am in or [are you] annoyed about my position because of my race? Race-Related Experiences Shape Interpersonal Interactions and Define the Institutional Climate Race influenced the professional lives of all participants. They described the effect of race on their relationships with patients, staff, and colleagues and its effect on their roles in the broader health care institutional envi

Mixed Methods in Health Sciences Research: A Practical Primer

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Professional experiences of international medical graduates practicing primary care in the United States.

BackgroundInternational medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.ObjectiveTo characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.DesignQualitative study based on in-depth in-person interviews.ParticipantsPurposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.ApproachA standardized interview guide was used to explore professional experiences of IMGs.Key ResultsFour recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of “the deal”; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.ConclusionsOur data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs’ experiences may also improve the experiences of an increasingly diverse healthcare workforce.

Media Exposure and Tobacco, Illicit Drugs, and Alcohol Use Among Children and Adolescents: A Systematic Review

The authors systematically reviewed 42 quantitative studies on the relationship between media exposure and tobacco, illicit drug, and alcohol use among children and adolescents. Overall, 83% of studies reported that media was associated with increased risk of smoking initiation, use of illicit drugs, and alcohol consumption. Of 30 studies examining media content, 95% found a statistically significant association between increased media exposure and negative outcomes. Similarly, of the 12 studies evaluating the quantity of media exposure, 67% reported an association with a negative outcome. Overall, all 17 of the identified longitudinal studies supported a causal association between media exposure and negative outcomes over time. The evidence was strongest for links between media exposure and tobacco use; it was moderate for illicit drug use and alcohol use. Substantial variability in methodological rigor across studies and expanding definitions of media exposure contribute to persistent gaps in the knowledge base.

Institutional Variation in the Promotion of Racial/Ethnic Minority Faculty at US Medical Schools

OBJECTIVES We compared faculty promotion rates by race/ethnicity across US academic medical centers. METHODS We used the Association of American Medical Colleges 1983 through 2000 faculty roster data to estimate median institution-specific promotion rates for assistant professor to associate professor and for associate professor to full professor. In unadjusted analyses, we compared medians for Hispanic and Black with White faculty using the Wilcoxon rank sum test. We compared institution-specific promotion rates between racial/ethnic groups with data stratified by institutional characteristic (institution size, proportion racial/ethnic minority faculty, and proportion women faculty) using the χ(2) test. Our sample included 128 academic medical centers and 88, 432 unique faculty. RESULTS The median institution-specific promotion rates for White, Hispanic, and Black faculty, respectively, were 30.2%, 23.5%, and 18.8% (P < .01) from assistant to associate professor and 31.5%, 25.0%, and 16.7% (P < .01) from associate to full professor. CONCLUSIONS At most academic medical centers, promotion rates for Hispanic and Black were lower than those for White faculty. Equitable faculty promotion rates may reflect institutional climates that support the successful development of racial/ethnic minority trainees, ultimately improving healthcare access and quality for all patients.

Race/Ethnicity and Workplace Discrimination: Results of a National Survey of Physicians

ABSTRACTBACKGROUNDPromoting racial/ethnic diversity within the physician workforce is a national priority. However, the extent of racial/ethnic discrimination reported by physicians from diverse backgrounds in today’s health-care workplace is unknown.OBJECTIVETo determine the prevalence of physician experiences of perceived racial/ethnic discrimination at work and to explore physician views about race and discussions regarding race/ethnicity in the workplace.DESIGNCross-sectional, national survey conducted in 2006–2007.PARTICIPANTSPracticing physicians (total n = 529) from diverse racial/ethnic backgrounds in the United States.MEASUREMENTS AND MAIN RESULTSWe examined physicians’ experience of racial/ethnic discrimination over their career course, their experience of discrimination in their current work setting, and their views about race/ethnicity and discrimination at work. The proportion of physicians who reported that they had experienced racial/ethnic discrimination “sometimes, often, or very often” during their medical career was substantial among non-majority physicians (71% of black physicians, 45% of Asian physicians, 63% of “other” race physicians, and 27% of Hispanic/Latino(a) physicians, compared with 7% of white physicians, all p < 0.05). Similarly, the proportion of non-majority physicians who reported that they experienced discrimination in their current work setting was substantial (59% of black, 39% of Asian, 35% of “other” race, 24% of Hispanic/Latino(a) physicians, and 21% of white physicians). Physician views about the role of race/ethnicity at work varied significantly by respondent race/ethnicity.CONCLUSIONSMany non-majority physicians report experiencing racial/ethnic discrimination in the workplace. Opportunities exist for health-care organizations and diverse physicians to work together to improve the climate of perceived discrimination where they work.

Gender and the pre-clinical experiences of female medical students: a taxonomy.

Medical Education 2011: 45: 249–260

Health care workplace discrimination and physician turnover.

OBJECTIVE To examine the association between physician race/ ethnicity, workplace discrimination, and physician job turnover. METHODS Cross-sectional, national survey conducted in 2006-2007 of practicing physicians (n = 529) randomly identified via the American Medical Association Masterfile and the National Medical Association membership roster. We assessed the relationships between career racial/ethnic discrimination at work and several career-related dependent variables, including 2 measures of physician turnover, career satisfaction, and contemplation of career change. We used standard frequency analyses, odds ratios and chi2 statistics, and multivariate logistic regression modeling to evaluate these associations. RESULTS Physicians who self-identified as nonmajority were significantly more likely to have left at least 1 job because of workplace discrimination (black, 29%; Asian, 24%; other race, 21%; Hispanic/Latino, 20%; white, 9%). In multivariate models, having experienced racial/ethnic discrimination at work was associated with high job turnover (adjusted odds ratio, 2.7; 95% CI, 1.4-4.9). Among physicians who experienced workplace discrimination, only 45% of physicians were satisfied with their careers (vs 88% among those who had not experienced workplace discrimination, p value < .01), and 40% were contemplating a career change (vs 10% among those who had not experienced workplace discrimination, p value < .001). CONCLUSION Workplace discrimination is associated with physician job turnover, career dissatisfaction, and contemplation of career change. These findings underscore the importance of monitoring for workplace discrimination and responding when opportunities for intervention and retention still exist.

Attrition from surgical residency training: perspectives from those who left.

BACKGROUND High rates of attrition from general surgery residency may threaten the surgical workforce. We sought to gain further insight regarding resident motivations for leaving general surgery residency. METHODS We conducted in-depth interviews to generate rich narrative data that explored individual experiences. An interdisciplinary team used the constant comparative method to analyze the data. RESULTS Four themes characterized experiences of our 19 interviewees who left their residency program. Participants (1) felt an informal contract was breached when clinical duties were prioritized over education, (2) characterized a culture in which there was no safe space to share personal and programmatic concerns, (3) expressed a scarcity of role models who demonstrated better work-life balance, and (4) reported negative interactions with authority resulting in a profound loss of commitment. CONCLUSIONS As general surgery graduate education continues to evolve, our findings may inform interventions and policies regarding programmatic changes to boost retention in surgical residency.

Socially-Assigned Race, Healthcare Discrimination and Preventive Healthcare Services

Background Race and ethnicity, typically defined as how individuals self-identify, are complex social constructs. Self-identified racial/ethnic minorities are less likely to receive preventive care and more likely to report healthcare discrimination than self-identified non-Hispanic whites. However, beyond self-identification, these outcomes may vary depending on whether racial/ethnic minorities are perceived by others as being minority or white; this perception is referred to as socially-assigned race. Purpose To examine the associations between socially-assigned race and healthcare discrimination and receipt of selected preventive services. Methods Cross-sectional analysis of the 2004 Behavioral Risk Factor Surveillance System “Reactions to Race” module. Respondents from seven states and the District of Columbia were categorized into 3 groups, defined by a composite of self-identified race/socially-assigned race: Minority/Minority (M/M, n = 6,837), Minority/White (M/W, n = 929), and White/White (W/W, n = 25,913). Respondents were 18 years or older, with 61.7% under age 60; 51.8% of respondents were female. Measures included reported healthcare discrimination and receipt of vaccinations and cancer screenings. Results Racial/ethnic minorities who reported being socially-assigned as minority (M/M) were more likely to report healthcare discrimination compared with those who reported being socially-assigned as white (M/W) (8.9% vs. 5.0%, p = 0.002). Those reporting being socially-assigned as white (M/W and W/W) had similar rates for past-year influenza (73.1% vs. 74.3%) and pneumococcal (69.3% vs. 58.6%) vaccinations; however, rates were significantly lower among M/M respondents (56.2% and 47.6%, respectively, p-values<0.05). There were no significant differences between the M/M and M/W groups in the receipt of cancer screenings. Conclusions Racial/ethnic minorities who reported being socially-assigned as white are more likely to receive preventive vaccinations and less likely to report healthcare discrimination compared with those who are socially-assigned as minority. Socially-assigned race/ethnicity is emerging as an important area for further research in understanding how race/ethnicity influences health outcomes.