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Black residents are forced out at far higher rates than white doctors – STAT


Rosandra Daywalker had always excelled. The daughter of Haitian and Jamaican parents in Miami — one an auto parts clerk, the other a nurse — she’d received a nearly perfect score on the SAT, earned a full academic scholarship to the University of Miami, graduated summa cum laude from Morehouse Medical School, and was inducted into the prestigious Alpha Omega Alpha medical honor society.

Then came the icing on the cake: She matched into the elite and highly competitive specialty of otolaryngology, a field she’d fallen for after watching an elegant head-and-neck cadaver dissection in medical school. Standing on the stage during Morehouse’s Match Day festivities in 2015, Daywalker beamed. Her family could not have been more proud. The fact that fewer than 1% of otolaryngologists are Black seemed a distant concern.

Her residency at the University of Texas Medical Branch at Galveston started well. She was the only Black trainee but felt welcome. She earned accolades and stellar reviews: “A well-liked team player.” “Always professional.” “Talented in the O.R.” She won a leadership award.

But when her supportive female program director left, everything changed. Suddenly, Daywalker could do no right. She was told she wasn’t closing cases fast enough, even though she thought she closed them as quickly as other residents. She was told to be on campus all day even though other residents often worked from home. Her previously excellent performance reviews dropped in every area. According to a lawsuit Daywalker brought against UTMB, she was intimidated in the operating room, denied rotations she requested, falsely accused of posing safety issues, subject to faculty members’ hostile comments about Black and Hispanic patients, and retaliated against for raising concerns about how a Black patient was treated.

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No matter how hard Daywalker studied and worked, she couldn’t seem to get traction. She started to doubt herself and suffered panic attacks. She couldn’t eat or sleep. When she returned from a medical leave, she was demoted. “I saw my wife go from being a super confident, growing superstar — in terms of medicine, she’s 10 times better than me — to just getting by, waking up anxious and depressed. It was really hard to watch,” her husband, Marcqwon, a family medicine attending physician at a health center outside of Houston, told STAT.

After more than three years of training, she left her residency in 2018. While she was not fired, the Texas Workforce Commission ruled she had been “constructively discharged,” meaning her workplace situation was so intolerable, she had no choice but to leave. “What’s painful is I wasn’t allowed to make that choice for myself,” she said. “It was stolen from me.”

Daywalker is not alone. A STAT investigation found that Black residents either leave or are terminated from training programs at far higher rates than white residents. The result of this culling — long hidden, dismissed, and ignored by the larger medical establishment — is that many Black physicians have been unable to enter lucrative and extremely white specialties such as neurosurgery, dermatology, or plastic surgery. It’s a key reason these fields have been unable to significantly diversify their ranks even as the total number of residency spots has increased nationally.

STAT spoke to more than a dozen Black residents and former residents who said they had been fired, forced out, or had withdrawn from residencies under duress. Many said they received unclear communication about what they had done wrong, were written up for transgressions that went unpunished for white residents, and were given little chance to address missteps or defend themselves. They called the appeals processes they had access to laughable and said their institutions, including human relations departments and offices for diversity and inclusion, did little to help them.

Being a doctor is not easy. And some percentage of trainees, regardless of race, are appropriately dismissed because they are not up to the job and might pose safety hazards to patients. The question is whether racism and bias cause some qualified residents to be unfairly dismissed. Data on residency dismissal by race have not been routinely collected by national medical organizations and are frustratingly difficult to locate. But the few numbers STAT could find are startling and lopsided: While Black residents account for about 5% of all residents, they accounted for nearly 20% of those who were dismissed in 2015, according to an unpublished analysis by the Accreditation Council for Graduate Medical Education.

That analysis showed that in every field examined, including specialties that have historically been more welcoming to Black physicians such as family medicine and pediatrics, Black residents were dismissed at rates higher than white residents. The same analysis showed that within the field of surgery, 12% of Black residents were dismissed in 2015, while just 2% of white residents were. (ACGME officials cautioned that the analysis should be viewed with caution because the numbers of Black trainees is so small.)

In the more elite medical specialties, the numbers may be even bleaker. A 2020 paper found that people from groups underrepresented in medicine make up 6% of residents in orthopedic surgery, but 17% of those dismissed. In neurosurgery, the numbers terminated some years are higher than 20%, said Owoicho Adogwa, an assistant professor of clinical neurosurgery at the University of Cincinnati who last year co-founded the American Society of Black Neurosurgeons to help stem high attrition rates. Only a handful of those who leave neurosurgery training programs are able to find spots in new ones, he said. Most switch to other specialties, often non-surgical, while some leave medicine altogether, still carrying the massive debt of their medical school loans.

Edjah Nduom, an associate professor of neurosurgery at Emory University and co-founder of the Black neurosurgery group, said with so few Black physicians in his field, each loss is devastating. In 2010, he said, there were five Black neurosurgeons among the 160 who graduated from residency programs, but four who left. In 2019, the last year for which he has data, nine Black neurosurgeons finished residency, while three left. “There are only 33 Black female neurosurgeons in this country,” he said. “If one in training doesn’t finish, you’ve just lost a unicorn.”

While much attention has been placed on increasing the number of Black students who enter medical school, little focus has been placed on how many people are lost during residency, the critical tail end of training, when young physicians are vulnerable to subjective evaluations that can be tinged by bias. Many say they are pushed out of elite surgical specialties toward family medicine or pediatrics where faculty tell them they are needed, without regard for the type of medicine they’d like to practice. To Adogwa, it’s a clear sign of gatekeeping.

“Why should we care?” Adogwa asked. “Because we are destroying the lives of these individuals and because we know, when providers don’t match the population, care suffers.”

Many residency programs are major money makers for hospitals because they can bill for the numerous procedures residents perform while paying them relatively low wages. But residents who leave or are fired after putting in years of working 100-hour weeks do not receive the economic payoff for all their hard work — something some Black physicians see as a modern-day form of indentured servitude.

“Why should we care? Because we are destroying the lives of these individuals and because we know, when providers don’t match the population, care suffers.”

Owoicho Adogwa, assistant professor of clinical neurosurgery, University of Cincinnati

Looking back on her experience, Daywalker — who has spent more than $50,000 on her lawsuit since it was filed in 2020 — feels she may have never had a fair chance because of her race. Despite her impeccable credentials and clear intelligence, she feels leaders of her program did not believe she could be an otolaryngologist because of the color of her skin. “Maybe,” said the soft-spoken Daywalker, “it was simply existing in a space where people like me are traditionally kept out.”

A spokesman for UTMB said he could not comment on personnel matters but that the institution “is committed to a work and learning environment that supports a culture of diversity and inclusion in which all individuals are treated with respect and dignity.” Other residency programs contacted by STAT for this article said, without commenting specifically on individual cases, that they similarly supported diversity and inclusion efforts and residents from different racial and ethnic backgrounds. The Accreditation Council for Graduate Medical Education, which oversees residency programs, said through a spokeswoman that the group provides residents with means to report programs that are not in compliance with rules but does not adjudicate disputes.

To many Black doctors in these lucrative specialties, the hemorrhaging of young doctors is a clear sign of systemic racism. How is it, they ask, that so many Black residents — who rank in the top of their medical school classes and often have the second degrees and research pedigrees needed to match into specialties at all — are being drummed out in exactly the same way? “When you have such a high attrition,” said Adogwa, “it raises the question, is something wrong with the applicants? Is something wrong with the screening? Or is something wrong with the system?”

Adogwa says it’s the latter, and points to unconscious bias by the mainly white faculty members who run residency programs as a significant factor. “If it happens with other residents, the response is ‘That’s why they’re trainees, this is what residency is for, to make mistakes.’ If it happens with a Black resident, the response is, ‘They’re incompetent,’” said Adogwa.

Black residents also told STAT they often felt isolated. Many said they suffered mental health crises and two told STAT they were so despondent they had considered suicide. Suicide is the leading case of death among male residents, according to a recent study that did not analyze the numbers by race or ethnicity. Three foreign residents at a Bronx hospital died by suicide last year, allegedly over abuse they received from supervisors.

Foreign residents face the additional stress of worrying about losing their visas and being deported if they are terminated. Jonas Attilus, a Black resident from Haiti who left his internal medicine training in Boston last year after what he described as a lack of support and unfair punishment, told STAT he became frantic and suicidal. “Even if you are the worst intern in the world, you don’t deserve to be treated like that,” he said.

In a statement, leaders from Boston Medical Center said they could not speak about individual residents but said they valued the diversity and life experiences of their residents and through recruitment efforts, 20% of the residents and fellows the hospital had trained were from groups underrepresented in medicine, a number far above the national average and that they provided numerous programs to support residents and counter bias.

Now in a new psychiatry residency program in Minnesota, Attilus was one of few interviewed by STAT to speak openly about his experience. Many residents who have left or been fired from their programs are reluctant to be identified because of the pain and shame involved. These experiences can be particularly traumatic for those who overcame adversity to reach college — many the first in their families to do so — and were celebrated as high achievers at their colleges and medical schools, only to be sidelined by residency.

“You hear, year after year, stories of people having their dreams wrenched away not because they were reckless, not because they couldn’t be part of a team or were technically incompetent, but because they didn’t have an environment that leveled the playing field,” Adogwa said. “What happens in residency is the same thing that happens in society: You have the same rules applying differently to different people because of the color of the skin.”

Daywalker was one of the few willing to tell her story publicly because she wants to help protect residents that come after her. After leaving the UTMB program, she specialized in occupational and environmental health medicine, earned a Ph.D. and was appointed chief resident in her new training program. Now thriving in a new job where she works with multinational companies, she is thrilled to be in a career in which she can bring her experience to bear. “I know too well,” she said, “the dangers of a toxic workplace.”

“Stupid.” “Lazy.” “Untrainable.” This is how many Black trainees — many who previously excelled academically — told STAT they were made to feel during residency. The stories they shared are so similar, they can sound like echoes.

They described getting criticized and written up constantly, sometimes for things they saw go unpunished for others. They said they lacked support from faculty and peers and faced a barrage of mistreatment — being mistaken for other Black residents, being asked to remove meal trays or take out garbage, and having their hair touched. They started to get anxious and lose sleep. Instead of getting more support and training after making a mistake, they faced higher scrutiny, overpolicing, and more negative reports. They were put on probation, but were afraid to ask for help. Then, they were quietly asked to leave.

“That is the playbook,” said Adogwa. He calls it “the death spiral.”

Such was the case for Fatu Conteh.

Conteh left Sierra Leone in 1999, a teenaged war refugee. She graduated from a magnet health sciences high school in Houston, earned a chemistry degree from Princeton University, and committed to becoming a physician after seeing the immense medical need during a trip back to her homeland.

She said she struggled at Rutgers’ Robert Wood Johnson Medical School due to her parents’ divorce but earned top scores on the Step 1 board exam used to assess mastery of scientific material, and became awestruck by neurosurgery. “There’s nothing so amazing as seeing the brain pulsate,” she told STAT, “and being able to navigate through that delicate environment.”

But her residency at the Medical College of Wisconsin was rough from the start. She felt she couldn’t do anything right. “I was told I was talking too loud, then I was told I was not talking enough,” she said. She said she was written up for minor transgressions that went unpunished for other residents. She said she wasn’t clearly told what she was doing wrong, or how to fix it.

She tried to remedy the situation by doing what she always had done to succeed: She woke up at 3 a.m. to study and studied more after her shifts ended, but it didn’t help. She said she stopped being given the chance to do procedures. “Those opportunities to learn that others were given, I wasn’t,” she said. “I had no help and I was scared to ask for help because they will use that against you.”

She left her program in June 2020, with both her spirit and her heart broken. “You’re getting people who truly love something to do something else, to settle for something they don’t love,” she said. “You know how painful that is?”

The Medical College of Wisconsin Affiliated Hospitals did not address Conteh’s complaints directly but confirmed she resigned and said through a spokeswoman that it’s “committed to fostering diversity, inclusion and equity and support of all our learners.”

STAT spoke with someone who was present in the residency program at the same time as Conteh to verify her claims. This person, who asked to remain anonymous so they could speak freely, said neurosurgery training can be “brutal” and that Conteh definitely should have received more support and feedback early on before it became too late to save her residency spot. The person confirmed that discipline in the program is uneven and that other residents had not been written up for mistakes or violations, such as lying. But the individual also did not think race was the major factor in Conteh’s dismissal, and said that while Conteh is extremely bright and hardworking and was well-liked, she had made missteps and was dismissed because she was seen as having trouble prioritizing tasks or presenting information efficiently — skills that are critical within neurosurgery.

These starkly different views of one residency experience show the difficulty of sorting through issues of race. What one person sees as someone falling short of valid standards and a justified dismissal, another may see as bias — as judging someone poorly, intentionally or not, because of their race. “Anti-Blackness is almost impossible to prove,” said Vanessa Grubbs, a Bay Area physician who spent a decade campaigning against the use of algorithms for treating kidney disease now seen as racist and recently co-founded a group called Black Doc Village to help Black residents who are struggling. “Anything short of calling someone a racial slur is seen as O.K.”

Much of the assessment of a resident’s skill and temperament is subjective, which can allow bias to seep in. “That’s the theme you always hear. ‘We don’t think they can process information quickly.’ ‘We don’t think they can handle making decisions in a high-stress environment,” Adogwa said. “Isn’t that what they said about women 20 years ago? Isn’t that what they said about Black quarterbacks wanting to enter the NFL?”

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These subjective criteria leave many Black trainees wondering, even years after they finish (or don’t finish) their residencies, what role race may have played. “Someone can look at my story and say you can’t definitively say this was a case of racial bias,” said a Black physician who withdrew from a surgical residency after being put on remediation made it impossible for him to succeed. He was told he “did not show enough interest,” he said, despite arriving earlier than colleagues for rounds and working just as hard, if not harder.

“What is hard because of the residency training, and what is hard because I look different and don’t fit the mold?” he asked. “Teasing that out is difficult.”

One of the motivations for diversifying the physician workforce is that physicians of color are more likely to better serve their own populations and work in underserved communities. No one exemplifies this more than Conteh, who is currently in Sierra Leone training with a pediatric surgeon. She recently spoke to STAT on a Zoom call illuminated only by the light of her cell phone because of a power outage. “This is how we roll,” she said.

She works in a hospital in the country’s capital, Freetown, which lacks a CT-scanner and an ICU, both essential for neurosurgery. Many people who require such operations, she said, are simply sent home to die. She’s joined with her country’s ministry of health to try to establish neurosurgery services and is determined to find a new residency program in the U.S. or U.K. so she can play a role. “I see what I can do,” she said. “I see what a difference I can make.”

If there’s one word that raises the ire of Black residents and physicians, it’s professionalism — a metric central to the assessment of young doctors but one that is so ambiguous it can easily be applied unevenly.

“That word always irritates me,” said Dowin Boatright, a Black assistant professor of emergency medicine at the Yale School of Medicine who has conducted studies on how race impacts medical training. Boatright, the only Black trainee in his residency a decade ago at Denver Health, had a mostly positive experience, but was repeatedly told to keep his hair trimmed short. “If there is a standard, it’s centered on white culture,” he said.

A study published in May in the journal Academic Medicine showed that internal medicine residents from groups underrepresented in medicine were rated lower than white trainees on five of the six core competencies on which they were judged; some of the largest differences came under the domain of professionalism, which the authors called “a hidden curriculum.”

“The standards reflect the people that teach — mostly white men — and the notion of what they hold as professionalism can trickle down insidiously,” said Robin Klein, an associate professor of medicine at Emory University and the study’s lead author. ”It opens up the door to enable bias.”

Professionalism can be used to tell people they are too loud, or too quiet, or that they need to dress or look a certain way. Many Black residents report an uncomfortable focus on their hair and whether they can wear locks or twists. “You can see I have a really big Afro, but I can tell you, I am always struck by medical school applicants who say ‘I didn’t think I could wear my hair that way,’” said Sheri-Ann Burnett-Bowie, a co-author of the study, assistant professor of medicine at Harvard Medical School, and associate director of the Center for Diversity & Inclusion at Massachusetts General Hospital. “There’s a lot of concern about fitting into the mold.”

The new paper is one of literally just a handful of studies to examine the role race plays in residency training. There is such a vacuum of information, and so much discomfort about the issue of race among white physicians, the authors said, that many who’d had difficult experiences in residency reached out as soon as the paper appeared. “So many people told us we’d validated their experience,” said Burnett-Bowie. “And these are some very senior people in medicine.”

“I had no help and I was scared to ask for help because they will use that against you.”

Fatu Conteh

The subject has been difficult to study because the numbers of Black and brown residents are so few, complicating statistical analyses. Perhaps for this reason, Klein said her study found only small differences between white residents and those from underrepresented groups.

The researchers are planning a larger study but said the small differences they detected were important, too. “These differences really do have consequences for someone’s professional trajectory,” said Burnett-Bowie. Even small differences in scores affect who gets selected for chief resident or special training or fellowship opportunities, and how glowing letters of recommendation may be. Consistently getting lower scores can erode confidence. “It’s all of the ramifications of not having your talents really seen,” she said.

The few papers that do exist offer distressing snapshots into what residents of color regularly face, and how this may contribute to their leaving or being dismissed from programs — from being called slur words by patients or “you people,” to being mistaken for each other or for hospital cleaning staff. They reinforce what some Black trainees told STAT, that they felt especially targeted by some white nurses who appeared to resent them. Others said they were not supported well by some Black faculty and senior residents, perhaps because those co-workers were traumatized themselves.

A 2020 survey of 7,000 residents found that nearly 25% experienced discrimination based on their race, ethnicity, or religion, with the highest rates for Black respondents. The study found this discrimination led to higher rates of burning out and not finishing residency.

A study published in 2006 based on interviews with 19 Black residents suggests it was an open secret back then that Black residents were being pushed out at high rates. “The residents who’ve been dismissed, in the last six years, they’ve been 100% Black,” one interviewee said. “People say they had it in for him, as a Black man,” said another. Added a third about a dismissed Black resident: ”I think if he was a white resident, I don’t think it would have gotten to that point.”

Of the 19 respondents in that 2006 paper, 13 reported seeing or experiencing unfair treatment, including termination, of Black residents. Black residents believed “they had fewer chances to make mistakes than their white counterparts,” and many grew to doubt themselves and said they felt “on guard at all times,” the authors wrote. Little, it seems, has changed.

Shenelle Wilson is now a rising-star urologist in Atlanta. But a few years ago, she was on the verge of walking away from her training even though her heart had been set on being a urologist since she’d moonlighted in the ER during medical school.

Day after day, she saw the same surgeon return to treat vastly different cases: a prolonged erection, a twisted testicle, and a kidney stone. “I said, ‘Wow, what are you?” she recalled. Wilson had never seen a female urologist — except for Kim Briggs on the TV show Scrubs — and had never seen a Black one. But this urologist, a white male, was happy to mentor her, a Black and Caribbean woman.

Wilson attended Morehouse, graduated magna cum laude from the Medical College of Georgia, was inducted into the AOA honor society, and had done well in her residency at Augusta University. “In all of my training, I’d never had a complaint from a nurse or anyone,” she said. “It’s almost impossible for a Black woman surgeon to do that.”

But her fellowship at the University of Alabama, Birmingham was a different story. She said she was criticized, belittled, and given warnings that seemed to make no sense. “I was told I was operating too fast,” she said. “But that was in all my letters, that I’m a nimble, talented surgeon.”

She said she was told she lacked scholarly activity, though that was not a requirement of the program and she had presented work at two national meetings. She said she also was not given the opportunity to travel with faculty to perform fistula surgeries in Tanzania, which was the main reason she’d chosen that fellowship program.

Selwyn Vickers, the dean of the Heersink School of Medicine at the University of Alabama, Birmingham, said in a statement that it would be inappropriate for him to comment on an individual fellow’s experience but that as a Black surgeon, diversity and inclusion were key priorities for him and an integral part of his medical school and health system’s values. The school has been named as a Diversity Champion in higher education by Insight into Diversity Magazine and the top employer for diversity by Forbes, he said.

Wilson said she was criticized for spending too much time with patients. But as one of very few Spanish-speaking physicians, Wilson found that patients wanted to talk with her about their health issues. She started to believe everything she was being told about herself.

“I was convinced I was lazy, I was stupid, how did I get this far,” she told STAT. “I was very much convinced that I wasn’t who I was. That’s why gaslighting is so effective.”

And so she decided to quit, with just a few months to go in her two-year fellowship. But the pandemic may have saved her career. A mentor convinced her to stay, and with most urology procedures on hold during the spring of 2020, she was able to rest, regroup, and eventually finish her training.

Wilson is now in private practice, specializing in female pelvic reconstructive surgery. She recently founded Urology Unbound, a group working to recruit, support, and encourage residents who are underrepresented in her elite field, where just 2% of physicians are Black.

And in 2021 she was named an American Urological Association Young Urologist of the Year.

Coming tomorrow: What will it take to level the playing field for Black residents?

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.

This content was originally published here.

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