Black Doctors Are Forced Out of Training Programs at Far Higher Rates Than White Residents

Rosandra Daywalker had always excelled. {snip}

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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 clinic notes 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.

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.

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.”

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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.

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“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.

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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?”

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. {snip}

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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 … applicants who say ‘I didn’t think I could wear my hair that way,’” said Sherri-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.”

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