Variegated racism: exploring experiences of anti-Black racism and their progression in medical education

Uncomfortable encounters and microaggressions

Several participants described situations where people within the college treated them differently or encounters that left them wondering if mistreatment was, at least in part, because of their skin colour. Experiences ranged from feeling diminished and disrespected by colleagues and superiors to domineering behaviours and harassment. Participants also described a tacit expectation that victims of racism should simply brush things off and move on. These experiences resulted in an environment where Black students felt incredibly vulnerable and insecure, with some stating that they felt they did not belong in medicine. A first-year medical student noted, for example, “I just know my presence within this field is not enjoyed by a lot of people because of my race” (Table 2). Others described microaggressions ranging from disrespectful to othering comments, such as questions that assumed they could not possibly be originally from Canada. In other situations, medical students recounted that they experienced racism through relentless questioning of their competence and scrutiny that filled them with self-doubt. One student described “pimping” (a form of on-the-spot oral quizzing, often in front of other learners, health care providers, or patients) from superiors. Although pimping is a common practice in medicine, a Black trainee who has previously experienced racism would be vigilant or primed to wonder if this treatment was because of their race. In addition, where such scrutiny was applied differently to a Black learner compared with their peers, as in the case of this student, it was experienced as a microaggression. These experiences highlighted encounters that left Black learners questioning their ability or place in medicine.

Blatant acts of racism

Participants also revealed that they faced situations where racism was not simply a subjective interpersonal experience but explicit and blatant. These ranged from the use of slurs by superiors, patients, and colleagues to obvious putdowns. In 1 instance, a student described superiors calling the Black Lives Matter movement stupid and claiming that Black people are dangerous (Table 2). In another instance, a resident revealed how a preceptor described a Black colleague in disparaging terms and repeatedly using the N-word in full. The preceptor had also described some people from Africa as “blacker than black, blacker than coal” (Table 2). Participants described racist abuse from patients and others within the clinical setting. Patients often made comments belittling Black residents or assumed they were not doctors. In many cases, Black learners looked to superiors to intervene, to no avail. Learners described several blatantly racist comments from patients, including a patient who claimed their child “usually cries around Black people” (Table 2). A resident described situations where patients explicitly insulted Black learners or compared them to social undesirables, including assuming that because of their beard, they must be “part of the Taliban” (Table 2). In these experiences, Black medical learners encountered overt racist abuse from superiors, patients, and colleagues. In most of these situations, learners suffered in silence because they believed they would be evaluated and viewed negatively for speaking out.

Curricular racism

Participants highlighted that they encountered racism in the curriculum either through the lack of representation of Black people or the disproportionately negative portrayal of Black bodies. Learners mentioned that they rarely ever encountered standardized and simulated Black patients. These realities limited participants’ learning experiences and made them unprepared to identify certain conditions in Black bodies. One participant noted, “For example, jaundice, something that’s common, they wouldn’t show how that presents in a Black individual” (Table 2). On the other end of the spectrum of curricular racism, participants noted that when the Black body appeared in the curriculum, it was often in a stigmatizing way with negative portrayals, such as consistent, disproportionate representations of the Black body with stigmatized conditions such as sexually transmitted infections. These descriptions revealed that the curriculum was another major site for the enactment of anti-Black racism through lack of representation and negative portrayals.

Medical hierarchies and racism

Another critical theme that emerged from our analysis was the fact that the very culture of the field of medicine can foster racism and unaccountability. A toxic combination of hierarchy, power, and prestige bred unaccountability expressed in blatant racism, intersecting with other forms of oppression and power. One student noted, for example, how specialists with years of experience often seemed untouchable. Others described how medicine’s hierarchies made students afraid of reporting superiors. One participant noted, “Medicine has this weird culture of there is the doctor, the residents, the junior residents, the senior med student, and the junior med student. If you’re above the person’s rank, you can do and say what you want” (Table 2). This hierarchical reality fostered racism. In the descriptions of their experiences, participants often referred to the system to acknowledge the differences between racism connected to interpersonal relationships and institutional racism connected to the very structure of medicine. Participants consistently expressed pessimism regarding any expectations of institutional change.

Misogynoir and intersecting oppressions

Racist experiences were often compounded for Black women medical students who were not always sure if experiences of mistreatment related to their gender, race, or a combination of both. Experiences of intersecting racism included “angry Black woman” stereotypes and dismissive behaviour of preceptors, colleagues, and patients. These experiences undermined the confidence of Black women medical students; 1 participant explained that being a Black female medical student often meant being taken less seriously than Black male, White female, and White male students. One participant noted “[in] some rotations I felt just a bit not as confident just by virtue of being a woman and being a Black woman” (Table 2).

In integrating the themes, we found that, participants’ responses followed a pattern where those in the early years of medicine perceived racism to be not too bad or provided instances limited to the curriculum, peers, or faculty. Learners in senior years, however, described more vivid examples of racism and highlighted sources of racism that went beyond curriculum, peers, or faculty. Learners in later years of training may have been more candid. Nonetheless, the diversity of sources of racist exposures revealed that, as learners progressed in medicine, moving further from the classroom and into clinical settings, sources of racist exposures increased. One might expect that as Black people progress in medicine, they gain more power that would protect them from racism. Counterintuively, experiences of racism may worsen partly because of increases in the sources of and exposure to racism. Drawing on the data, we illustrated this phenomenon in Figure 1.

Figure 1:

Racist exposures in medical education for Black learners.