In a new study, Yale researchers show that students from marginalized groups leave medical school at higher rates than their classmates. The findings, the researchers say, have implications for health care access and patients, both of which are harmed when the medical workforce lacks diversity.
The study was published July 11 in JAMA Internal Medicine.
Medical schools and the organizations that accredit them have placed an increased focus on recruitment strategies that build more diverse student bodies, says Dowin Boatright, assistant professor of emergency medicine and senior author of the study. And those efforts have helped.
“We are reaching a state now where there should be more attention put on retention,” he said.
For the new study, Boatright and his colleagues analyzed data from students who matriculated at U.S. medical schools during the 2014-2015 and 2015-2016 academic years. They assessed attrition rates across individual and structural measures of marginalization, which included race/ethnicity, family income, and whether students came from an underresourced neighborhood, defined as neighborhoods with too few health care practitioners to meet community needs.
They found that students who identified as an underrepresented race or ethnicity, came from a family with low income, or came from an underresourced neighborhood were more likely to leave their programs early than students not from a marginalized group.
Additionally, students who identified with multiple marginalized identities — such as having families with low income and coming from an underresourced neighborhood — had even higher attrition rates.
The highest attrition rates were observed among students who identified with all three of the marginalized groups the study analyzed.
“We know that each marginalized identity brings its own unique challenges,” said Mytien Nguyen, an M.D.-Ph.D. student at Yale School of Medicine and lead author of the study. “So with multiple marginalized identities, we have compounding challenges.”
Added Boatright: “It’s an accrual of disadvantage.”
The research team proposed several actions that could help address the problem. Accreditation organizations that already assess the diversity of medical schools’ matriculating students could extend that to retention, they say. And medical schools themselves could consider tuition and debt reform, more flexible training pathways, and a greater focus on mentorship.
Addressing the negative experiences some students are subject to — such as discrimination, mistreatment, and cultures of exclusion — would also help, they say.
“In terms of students’ experiences of mistreatment, some are due to overt biases, but some are due to implicit biases,” said Boatright. “I think programs have done a lot to try to address implicit bias, mainly through things like implicit bias training, but the data behind most interventions being used are mixed at best.
“One of the more evidence-based methods for decreasing implicit bias and improving inter-group contact is increasing the number of faculty from diverse backgrounds. It’s a very simple intervention that I still don’t think many medical schools pursue.”
Additionally, the researchers say medical schools’ retention efforts should switch from deficit-based models, which focus on perceptions of what students are missing or need to catch up on, to strength-based models that promote the characteristics, skills, and talents that schools want to amplify.
“Implicit in the deficit-based model is something being wrong with an individual or students from a marginalized community, which already signals a perception of inferiority,” said Boatright.
“The admissions committee has already determined that these students are fit to be doctors and are academically ready,” said Nguyen. “These are not individual challenges, but challenges students face because the medical school environment, climate, and system are not created for students from these marginalized backgrounds.”
Going forward, Boatright, Nguyen, and their colleagues are looking into what schools with lower attrition rates are doing to achieve that, strategies that encourage students to change their minds when they consider leaving medical school, and why leaves of absence often lead to attrition.
Ultimately, Nguyen said, the problem often comes down to nurturing versus surviving.
“I think students from non-marginalized backgrounds are really being nurtured while students from marginalized backgrounds are surviving,” she said. “And biologically, when you’re surviving and managing stress, you’re not able to perform at your best. With every student that leaves, it’s not just a loss for the health care industry, but a loss for our patients as well.”