Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program

Abstract

IMPORTANCEMedical trainees frequently experience discrimination. Understanding their experiences is essential to improving learning environments. OBJECTIVE To characterize trainee experiences of discrimination and inclusion to inform graduate medical education (GME) policies. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used an anonymous telephone interview technique to gather data from hematology and oncology fellows. All current trainees and recent graduates were eligible. Interviews were conducted anonymously with interviewer and participant in separate locations and recorded and transcribed. Data were analyzed in an iterative process into major themes using a general inductive analysis approach. Demographic information was obtained via anonymous survey. Data collection and analysis were conducted from July 2018 to November 2019. MAIN OUTCOMES AND MEASURES Emergent themes illustrating bias and inclusion in a GME program. RESULTS Among 34 fellows and recent graduates who were approached for this study, 20 consented and 17 were interviewed. Of those interviewed, 10 were men, and the median (range) age was 32 (29-53) years. The racial and ethnic distribution included 6 Asian individuals, 2 Black individuals, 3 Hispanic individuals, 2 multiracial individuals, and 4 White individuals. All fellows reported having experienced and/or witnessed discriminatory behavior. The themes elucidated were(1) foreign fellows perceived as outsiders, (2) US citizens feeling alien at home, (3) gender roletyping, (4) perception of futility of reporting, (5) diversity and inclusion, and (6) coping strategies.The majority of reported biases were from patients. Only 1 trainee reported any incidents. Reasons for not reporting were difficulty characterizing discrimination and doubt action would occur.Participants reported that diversity of cotrainees, involvement in committees, and open discussions promoted inclusivity. CONCLUSIONS AND RELEVANCEIn this study, reports of discriminatory behavior toward trainees were common. The anonymous hotline methodology cultivated a safe environment for candid discussions. These findings suggest that GME programs should assess their learning climate regarding bias and inclusivity anonymously and develop processes to support trainees.

Exploring Teamwork Challenges Perceived by International Medical Graduates in Emergency Medicine Residency

“…A salient perception by non-US IMGs was the need to assimilate to the dominant culture and hinder self-expression to build rapport and improve evaluations. Participants felt penalized for behaviors deemed appropriate in their home culture, which is unfortunately consistent with prior reports 9 , 14 , 38 and probably stems from the lack of cultural competence in healthcare. 39 , 40 A specific example is the negative feedback for lack of assertiveness mentioned by our participants, which has been reported by ethnically diverse medical students, 41 as well as female resident physicians.…”

Challenges for International Medical Graduates in the US Graduate Medical Education and Health Care System Environment: A Narrative Review

“…Discrimination is a major issue in US GME as it seems that the focus is entirely on the assimilation of the new culture without an appreciation of being different [39]. This phenomenon is seen in all levels of the US HCS, from patients and family members to colleagues and superiors, adding that IMGs have been historically confined to less-desirable specialties and locations [26].…”

“…Interviews led by investigators of a fellowship program revealed that not only foreign graduates but also USMG treated as a foreigner (for having accent) are subject to racism [39]. In many cases, discriminatory behavior comes from patients [27], and these events are rarely conveyed to authorities either because offended residents are not aware of policies for reporting patient discrimination or concerned about retaliation [39].…”

“…Interviews led by investigators of a fellowship program revealed that not only foreign graduates but also USMG treated as a foreigner (for having accent) are subject to racism [39]. In many cases, discriminatory behavior comes from patients [27], and these events are rarely conveyed to authorities either because offended residents are not aware of policies for reporting patient discrimination or concerned about retaliation [39]. This concealing behavior was recorded in another study assessing residents' transcultural experiences in caring for patients, where discrimination complaints made by IMGs in previous individual interviews were omitted, perhaps voluntarily, following group sessions involving USMG [27].…”

Dónde Están? Latinx/Hispanic Representation in the Oncology Workforce: Present and Future

“…Trainees and junior faculty from UIM groups often face hostile environments during training and after they have joined the oncology workforce, including daily microaggressions, exclusion from leadership positions, and not receiving the appropriate mentorship and sponsorship. [82][83][84] It is often believed that Latinx/Hispanic trainees and faculty should be mentored by faculty or leaders with the same cultural or ethnic backgrounds. However, as described in several sections of this article, there are not enough senior Latinx/ Hispanic faculty to mentor the new generation of oncologists.…”