Medical school affiliates on lack of diversity, burden of the ‘minority tax’

July 31, 2020, 11:25 a.m.

In the wake of a mass movement against racial injustice and police brutality in America, affiliates of Stanford Medical School are speaking up about their experiences with institutionalized racism in the field of medicine and championing diversity initiatives at Stanford. 

Students from underrepresented minority groups make up 20% of all graduate students at Stanford and 6% of all postdoctoral scholars at the School of Medicine. Similarly, underrepresented minorities make up 6% of professoriate faculty and 13% of staff.

Associate Dean of the Office of Student Medical Affairs Mijiza Sanchez-Guzman, who serves on the School of Medicine’s diversity cabinet, said that being one of few people of color in a department is a common source of anxiety for many underrepresented minorities in medicine. 

“There’s not a lot of us in the field, and so for the ones of us that are here, there’s a minority tax,” Sanchez-Guzman said. “It’s the stress of having to serve on every committee and having to do everything — it’s a lot, it’s a burden.” 

A ‘leaky’ recruitment pipeline 

Affiliates cited recruiting as a pivotal step towards fostering a diverse and inclusive environment, stressing the importance of starting at the application process.

“There is a leaky pipeline when it comes to education leading to the field of medicine,” Clinical Assistant Professor of Pediatrics Lahia Yemane told The Daily. “There are many points where we are losing folks from underrepresented backgrounds. It goes back all the way to what your teachers are telling you that you can and cannot do in elementary school.” 

She added that bias and racism in college advising contribute to racial disparities in medicine. 

“There are a lot of people who start out as pre-med and drop out,” Yemane said. “Unfortunately many of these end up being minority students because they are faced with barriers to succeeding. Advisors are the gatekeepers and often tell students when they get a B or C on that test that they shouldn’t be pre-med anymore.” 

Yemane told The Daily that these barriers include academic backgrounds that do not prepare minority students for college pre-med classes, financial barriers and racial stereotypes that peg these students as “weak.” 

“Medical school and medical training are in general very expensive,” Yemane said. “That in and of itself is a deterrence. To make a commitment to medical school, there are enormous costs.” 

The price of medical school is apparent as early as the application process; both medical school programs and residency programs often require applicants to fly to campus for in-person interviews, which can end up costing thousands of dollars. According to Yemane, this is emblematic of the process and the result: most medical students come from families from the top two quintiles for income status. 

“The system is not set up for folks that don’t have a lot of money, and there’s bias through each step of the process,” Yemane said. 

School of Medicine Scholar in Residence Arghavan Salles M.D. ’06 Ph.D. ’14 echoed Yemane in saying, “There are a lot of factors that make it so that the people going into medicine are the same group over and over again.” 

“You have to fly to every interview on your own budget and stay at a hotel. And of course it’s very competitive so people go to as many interviews as they can. All of that creates barriers for people who don’t come from wealthy families,” she added.  

Sanchez-Guzman pointed out that at Stanford, potential students also have to worry about studying in a place with high housing and living costs. 

“Students and residents alike say, ‘I don’t know if I could afford to live here on a resident salary,’ and that’s real,” Sanchez-Guzman said. “As administrators we can try to work with University leaders and offset or subsidize some of these burdens, but due to the high cost of living in the Bay Area it’s ultimately out of our control.” 

However, she said, this does not mean that the University should give up. 

“Recruitment is paramount because when people from underrepresented backgrounds can see themselves here, they’re more likely to want to come here,” Sanchez-Guzman added.

“When they see people who look like them thriving, not being burdened by being on every diversity committee, and living their best lives, they are likely to think,  ‘okay, I could see myself there.’ And often that is what makes the difference”. 

Salles said that medical institutions need to do a better job of reaching out to traditionally underrepresented communities in order  to select diverse applicants from a pool of potential students or faculty members. 

“We have a huge challenge recruiting Native people,” Salles told The Daily. “The percentage of faculty across the country in academic medicine who are indigenous is less than 1% of all faculty, and Black and Latinx faculty members are each only 2% of our total population.” 

She noted that these statistics pale in comparison to the make up of the national population, which is 13% Black and 18% Latinx. 

“We have either not made the career welcoming to people who are not White or Asian, or we have not removed barriers for those people to get into the profession,” Salles concluded. 

“You can’t be what you can’t see,” Yemane added. 

‘Cultural change must follow’

Affiliates stressed that the recruitment process is only the first step. Cultural change must follow. 

“We need to figure out a way to make sure that people who are coming in with a different perspective actually feel included,” Salles said. “Recruiting people who look different is a challenge but it’s not insurmountable — there are excellent candidates at every level. But those people come to the institution, and if the culture around them expects them to fit in to be just like everybody else, that’s where the diversity fails. There’s a common saying that diversity without inclusion is really exclusion, and I think that’s what we’re seeing at a lot of places. 

“It’s one thing to get people through the door, but it’s another to have them stay and really feel valued,” Yemane added. 

Affiliates said that a true culture shift will only come when the University takes proactive measures towards progress, such as pipeline programs and supporting existing diverse faculty and students. . 

“I’d rather work more proactively rather than reactionary,” Sanchez-Guzman said. “I feel like a lot of work that we’ve been doing is in response to what’s happening in the community and the country rather than just doing what we should be doing.”

“This issue obviously started over four-hundred years ago,” Yemane said. “And now it’s not that there has to be a tragedy for us to do something. We already know that discrimination is  happening and we need to be figuring out how can we as an academic institution do better.”

Fifth-year medical student Osama El-Gabalaway B.A ’15 M.S ’16, who is the outgoing chair of Stanford University Minority Medical Alliance (SUMMA) added that the University’s reaction should be thoughtful and inclusive. 

“After tragic crises boil over the country or locally, the University twiddles its thumbs, and puts out half-baked PR statements,” El-Gabalway said. “One of our goals is to bring the stakeholders into the room where the decisions are made. For example, if there is a Muslim ban, the University should bring Muslim facutly and students to the table and center their voices.” 

A history of racism, pushed under the carpet

Affiliates said that the University could not succeed in creating a diverse and inclusive environment without acknowledging and addressing the legacy of racism in modern medicine. 

“We want anti-racist history within medicine,” El-Gabalway said. “Every section of the curriculum should dedicate time to the history of exploitation of people of color.” 

He pointed to the Tuskegee Syphilis Study, in which researchers experimented on Black men, intentionally withholding treatment from a control group, and the forced sterilization of indigenous communities as evidence of what he calls “a discipline built on exploiting minorities’. 

“Sometimes they say ‘oh a risk factor for this disease is race,’’ El-Gabalway said. “But it’s not race — it’s racism that creates the health disparities. That gets kind of pushed under the carpet here. There’s huge amounts of historic distrust and huge amounts of health disparities, so without Black doctors and people within the institution fighting for the change that they know their communities need, none of that trust can be restored or fixed.” 

Programming to process and heal

Many affiliates have taken matters into their own hands, championing their own diversity initiatives at Stanford.  El-Gabalway said that progress was often “frustratingly slow” in his experience fighting for an inclusive curriculum and diversity resources and funding. 

El-Gabalaway was one of many students who advocated for the Diversity Center of Representation and Empowerment, or “D-CORE,” which “provides a space where any member of the Stanford Medicine community interested in issues of inclusion and diversity can hold meetings or just hang out and study,” according to the D-CORE website.  

“The D-CORE came on the heels of the last BLM wave, ” El-Gabalway said. “There were a ton of notes that were shared between Ph.D. students, masters students and medical students, and these groups joined and put together a proposal of 10 points for the administration.” 

One of these points, El-Gabalway said was a physical space on campus for students of color in the medical school to congregate and organize. 

Other requests outlined in the October of 2016 letter included hiring a full-time Chief Diversity Officer, mandatory diversity training for all community members and a published strategy for recruiting more faculty members form underrepresented groups. 

Dean Minor responded to the letter by implementing the D-CORE over the course of the 2016-2017 school year, officially opening the space in October of 2017. 

While the D-CORE was a success for student advocates, securing funding presented more of a challenge, El-Gabalway said.   

“There were points where we ended up having to beg from different departments, which was a painful, slow, labor-intensive and arduous process,” El-Gabalway added.

He added that advocates have experienced pushback when asking for pay for students who are working on fostering diversity and inclusion. 

“The burden is on the students to make change,” El-Gabalway told The Daily. “The challenge is getting the University to compensate students who often go unpaid for the labor they put into this.”

“Every time we bring this up, the administration says, ‘your payoff is seeing this place become a better school,’” El Gabalway continued. “And while that seems nice that’s not really a sustainable method. The administration makes students put in all the work and when things go bad, the students take the fall.” 

“They are using students to shield themselves from the really hard responsibility of creating sustainable change,”  El Gabalway added.

Community members have also been working to foster diversity and inclusion at the residency and fellowship level. Yemane is the co-director of Stanford Medicine Leadership Education and Advancing Diversity (LEAD), a program she helped found in 2017 with the goal of creating diverse leadership at Stanford Medicine through training and mentorship. 

The 10 month program meets once a month for two hours. In this time, residents and fellows engage in case-based discussions, attend interactive lectures on diversity and leadership and work in small groups to create workshops with the values of equity and inclusion in mind. Past group projects include designing curriculum about empowering providers to improve the care of patients with Limited English Proficiency (LEP) and researching the effects of implicit bias in performance evaluations. 

The program started in the Department of Pediatrics, but expanded to other departments very quickly, and in 2019 tripled in size and went across all departments in the School of Medicine.

“Every year as we get bigger and bring in more folks, we also bring in a sense of community,” Yemane said.

Yemane says that the program also provides students with the opportunity to share personal stories of microaggressions and discriminating, allowing them to process and heal. 

A marathon, not a sprint

As an avenue for making progress towards fostering an inclusive culture, Salles has championed creating an accessible and streamlined process for reporting incidents of discrimination.

“These issues are very complicated because if you think about just one incident where something inappropriate is said to someone, reporting those types of incidents is not straightforward and often does not benefit the person who is doing the reporting,” Salles said. 

“As long as that continues to be the case, people will be hesitant to report, and as long as people aren’t reporting we don’t know what’s happening. If we don’t know what’s happening, we can’t make change,” she added.  

She argued that appointing a diversity officer or commissioning a committee to look into discrimination was not enough to eradicate racism and other forms of discrimination. 

“When incidents happen, the University creates commissions and task forces and committees hoping that something comes out of those, but these bodies aren’t always empowered to make change,” Salles told The Daily. “People often create a Chief Diversity Officer role…  and they think that dedicating salary to a human is going to solve the problem, but that one person cannot change the culture of an institution.”

Salles added that these commissions need to include diverse perspectives. 

“We see a lot of people creating committees or task forces where they don’t include people from all different backgrounds, so we need to make sure there’s diversity at each level ” Salles said. “The more we can take into account different perspectives the better the solutions will be.” 

Affiliates also stressed the importance of mentorship. 

“In many places they just match new hires up with people in their department, and although they have something in common, it’s hard for them to speak freely because those are the same people that are going to be involved in assessing them for a promotion or a performance review,” Salles said.  

“That’s why it’s so important to help people from underrepresented backgrounds identify mentors who understand University policies and procedures,” she added. “Black and Latinx faculty don’t get promoted at the same rate as white faculty, so helping people understand early on what milestones they need to meet for promotion would be really helpful.”

“Mentorship is one of the big keys to helping keep people of color and underrepresented in medicine folks in academic medicine,” Sanchez-Guzman added. 

El-Gabalway called upon the University to implement mandatory anti-racism training and fully-funded diversity positions as integral solutions. 

“When the School of Medicine was trying to devise a split curriculum, they brought in consultants and experts and did paid focus groups,” El-Gabalway said. “So we know they’re capable of doing things, and we want them to attack anti-racism training with the same rigor and same funding that they do with other things.” 

El-Gabalway requested research assistantships within the Center of Excellence and Diversity in Medical Education, funded teaching assistantships and funding for student research projects that explore racism in the field of medicine. 

University President Marc Tessier-Lavigne recently announced a number of initiatives intended to combat anti-Black racism at Stanford, including new diversity and inclusion fellowships and added support for research on race. 

“The University releases metrics, but doesn’t act upon them,” El-Gabalway told The Daily. “We want them to present precise strategies. They love the term  ‘precision medicine’ and we want them to weaponize that term to attack the lack of Black and minority faculty with the same rigor as other issues. We want to see them attack retaining faculty of color.” 

Finally, El-Gabalway asked the School of Medicine to provide mental health support for Black and other minority trainees. 

“Oftentimes, even after George Floyd, we were using Black faculty we know to do healing circles,” El Galabaway continued. “They do that out of labor of love, but we want that to be compensated because. It’s not fair that we expect Black faculty to do these tasks without compensation or recognition for what that is worth”. 

Yemane stressed the importance of capitalizing on this time in history at which equity and inclusion are at the center of discourse. 

“We need to be sure to not lose this moment and to really affect change,” she said. “A lot of people of color are cautiously optimistic right now. It’s nice to hear the words, but we want to hear that there is true action and change. This is a marathon, not a sprint, and to really be anti-riacst is going to take active work.” 

Salles echoed Yemane, stressing substance over form. 

“It’s really important for people at the top of an organization to not just say the right thing but to really be devoted to these problems,” Salles said. “That dictates the culture of the organization all the way down. When people see someone saying the right things but never doing the right things, then they don’t really believe that that person is truly committed to that issue.” 

“That feeling of it being disingenuous is really damaging to minoritized groups or marginalized groups.” 

She concluded by arguing that diversity and equity are important because they empower institutions to work at their best. 

“I think that we’re seeing more and more that ultimately having a workforce that is diverse is the best way to deliver care,” Salles said. “Even if all you care about is providing quality care to patients, you have to realize that having a diverse workforce is key to that mission.” 

This article has been updated to clarify that the LEAD program includes participants at both the residency and fellow levels.

Contact Sarina Deb at sdeb7 ‘at’ 

Login or create an account