“Are you a left-sider or a right-sider?” my classmate asked with a puzzled look during an end-of-the-year dinner among first-year medical students. I was confused. He repeated himself then answered. “Do you sit on the left or the right side in class … that’s right; you sit on the right.” He then mentioned that everyone present was a “right-sider.” Nearly everyone was white.
For the past 18 months, we sat in a racially arranged way in class: most white people were concentrated on the front to the middle right of the auditorium, black women sat the furthest back, and everybody else sat on the left side with few exceptions. This arrangement translated to the lunch tables and other social settings. We may, at first, think of this divide as different parties sharing equal responsibility, but we live in a society where minorities still have negative experiences in today’s integrated schools. These experiences are linked to a history of structural racism: negative media portrayal, policies perpetuating segregation and impeding upward mobility for racial and ethnic minorities. They experience isolation in different ways, and one of the common coping mechanisms is in-group separation out of self-preservation.
Beverly Tatum expounds on this in her book Why Are All The Black Kids Sitting Together at the Cafeteria Table? She describes different groups’ experiences with race and explains the burden on minorities, especially blacks and Latinos. Self-segregation happens out of self-preservation from macro and micro-aggressions; they need support and cultural understanding from their peers, but also feel less valued and invisible among their white counterparts. This is exacerbated by the landscape in our institutions. The portraits that adorn the walls of our study spaces are almost entirely of white male physicians. I believe the unintended racial segregation happening in lecture halls and social circles may have a long-term negative impact on interactions with our colleagues and patients from different backgrounds, and we should use the resources and structures in place to address this earlier in the medical training.
Research shows that medical students and physicians have similar results on implicit-association tests when it comes to anti-black bias. Practicing physicians are, however, are more likely to act negatively on their biases in clinical encounters. It has been shown that medical school experiences are associated with change in student implicit racial attitudes. Throughout medical school, we are primed by negative comments and portrayal of minority patients through clinical vignettes and in-hospital experiences.
Evidence shows the negative impact of implicit bias particularly on black and Latino patients. Both groups are underrepresented among physicians, while Asian and white doctors are well represented. Studies show that the most effective way to counter one’s biases is to develop positive relationships with members of the “out-group” in question.
The medical field’s attempts to mitigate the effects of implicit bias have so far intuitively focused more on the clinical years. This is manifested via education for trainees and attending physicians, including diversity training, and more informal ways such as book clubs. We pay less attention to the preclinical years. For preclinical students like myself, structures to contribute to addressing implicit bias already exist. Targeting ways in which students interact with peers is an option. Several national organizations are calling for the emphasis of teamwork in medical school, and those changes are implemented in our introduction to the clinical world, including the more recent emphasis put on interprofessionalism. The intentionality driving interprofessional experiences where medical students work with allied-health peers can be mirrored in ensuring that group experiences for preclinical students reflect the diversity of their environment. Staff mention that gender balance is important when creating groups for longitudinal experiences. What if, paired with the emphasis on the importance of teamwork and diversity, groups were intentionally made to be diverse beyond gender?
Further de-randomizing groups could afford more predictable opportunities for students to interact with peers from different backgrounds in settings that may contribute to creating great relationships. As many medical schools thoughtfully shift towards flipped classroom and team-based learning models, students have more opportunities for interactions across professions, levels of training and social groups. Some may argue in favor of group homogeneity. This is, however, a mechanism already in place through extracurricular social networks and affinity groups, often institutionally supported.
Changes to the landscape could have a positive effect on what students value. Given that the portraits adorning the walls of our schools recognize mostly white men, we should restructure the ways in which space is allocated for portraiture. For example, allocating space recognizing students, recent alumni and faculty for their academic prowess could contribute to a landscape more reflective of its dwellers. While social scientists refer to the concept of landscape fairness as aiming to remove forms of discrimination in a built-in environment, I aim to emphasize the importance of recency in the landscape, related to not only fair representation but also temporal proximity for students with respect to those who are celebrated through portraiture. Such recency is likely more inspiring because of commonalities afforded by aforementioned proximity. For example, as a freshman at Howard University, I was inspired by portraits of seniors and recent alumni who were Fulbright fellows and Rhodes scholars because I saw myself in them.
As we aim to mitigate the impact of implicit bias on clinical care, we must remember that bias is not isolated to clinical settings and has effects on interpersonal relationships within the profession. We must also note that negative implicit attitudes towards racial and ethnic minorities in our society are a part of the larger issue that is structural racism. Addressing implicit bias must be done well before the clinical years through a longitudinal approach, but it must also be part of larger synergistic efforts aiming to combat structural racism and the ways in which it affects health.
The author would like to thank Douglas Shenson, MD and Benjamin Oldfield, MD for their guidance in the conceptualization of this article. Max Jordan Nguemeni Tiako is a medical student.