It was a Thursday night, and I was with my two friends, Jess and Kevin, on the dark road back to Boston. We were on our surgery rotation in a distant town. During the week, we cohabitated in a bare-necessities house near the hospital. As the only one with a car, it became my routine to wait until everyone’s long shifts were over and drive everyone back. We tended to fill these rides with conversation, the topic of which was often our experiences on the wards. Tonight was not any different.
Trying to keep my tired eyes on the road, I just listened to Jess and Kevin talk.
The conversation turned to the concept of “imposter syndrome” — that feeling of not belonging in a space you were accepted into institutionally. Kevin described how all of third year has been draining in an unexpected way. He went on to say it has been hard for him to be himself completely, or to feel like he fits in. Jess validated this and brought up that it probably had a lot to do with how they were raised.
For context, Kevin is Vietnamese and Jess is Chinese. They got to discussing the similarities in how they were brought up — how respect for parents and other older family members was paramount and manifested in actions, not just words. For them, as children, it was not socially acceptable to speak up to or question a senior family member. The connection between this upbringing and their ability to navigate the archaic hierarchy of medicine was not lost on them. It was not easy for them to speak up or chime in during rounds, to offer their knowledge or perspective to a group of seniors.
At that point, a lightbulb went off in my own inner monologue: of course.
Before witnessing this conversation, if you had asked me how it feels to be a part of the medical teams, I would have said easy. I would have bragged about my ability to speak up to superiors — how I easily fight for a plan others initially disagree with or bring up more radical advocacy notions that question someone’s management. These are things I have come to hold as core aspects of my personality. In listening to Jess and Kevin, I realized how ignorant that really was.
What I have been interpreting as character traits are products of my White cultural upbringing. In my life, less emphasized were the values brought up by Kevin and Jess in the car that night — that of respect for authority and the importance of group cohesion over the needs of the individual. While I am not implying this is the situation for all students of Asian descent, it was a clear cultural difference between me and these two friends. My upbringing placed more value on individual expression, achievement, and choice. From childhood, I have been primed to speak up and demonstrate my ability, regardless of who I am speaking to. In fact, it has been encouraged. And this has served me well on the wards.
Feeling that my voice is wanted and even necessary in the clinical setting does more than ease my experience, it offers tangible benefits. To understand how, it is necessary to understand how we are assessed.
Medical students receive “clinical grades” that transform their performance in the clinical setting into a numerical or categorical term. Some components of these evaluations include knowledge, measured by our ability to diagnose and plan for a patient’s care. In practice, the moments to showcase our skills are not clearly defined. So, demonstration of knowledge involves both successful identification of those moments and what many physicians label as “confidence” to seize the moment. Over and over again I have heard seniors tell students, “It doesn’t really matter what you say for a diagnosis or plan, just say it with confidence.” This confidence emphasized by evaluators, who are responsible for our grades, is not an objective measure of ability, but instead the result of how comfortable a medical student is in a space. And if you are White, I promise you are probably a lot more comfortable than a student who is not.
You are more comfortable because you are familiar with the culture of medicine, and how to navigate it. This is because, in many ways, the culture of medicine is White culture. White physicians make up 56% of the workforce, more than any other race or ethnicity. I have been on a variety of medical teams during my third year, but it is safe to say the majority of those teams were White people. I knew I moved through these spaces easily for many reasons, but being White is a big one that needs to be said out loud. And when you look and feel more comfortable in a space, it is easier to perform “well,” or to sound confident. This is directly related to what academic medicine characterizes as “objective” evaluations of students, and there is data to support this.
A study summarizing 6,000 Medical Student Performance Evaluations found that White students were more likely to be described as “standout” and their abilities to be “exceptional” and “outstanding.” Black students, meanwhile, were more likely to be described as “competent.” They found that medical students who were not White received lower grades than White students in most of their clinical clerkships. These clinical grades carry weight — not only do potential residencies see them; they are also used to select for prestigious society memberships such as Alpha Omega Alpha. White students are 6 times more likely to be inducted into Alpha Omega Alpha compared to Black students, and 2 times more likely compared to Asian Students.
As we neared our exit, I shared my own experience with Jess and Kevin, detailing my surprise at never having developed the dreaded “imposter syndrome.” I told them how listening to their conversation made me realize, and more critically evaluate, the reason behind this. I know a lot about White privilege and the socioeconomic implications of it. Medical schools actually elucidate the results of White privilege by teaching us about racial disparities. But we rarely discuss the huge ways in which the predominant White culture of medicine diminishes the subjective experiences of minority students and their “objective” evaluations.
This moment in the car on the way home was an important reminder of that.
But this reminder needs to go further. There are many ways in which I, as a White medical student, can improve this problem. For example, I can make note of when I need to pipe down and instead help amplify another student’s voice while in the clinical setting. I can support students who have adverse experiences due to their race by joining their voice when they speak to the administration. The reflection I engaged in in the car was a passive happenstance, but active and continued reflection, instead of when prompted by students of color, is critically important. Additionally, it is crucial we support institutional-level change. For instance, some schools are suspending their affiliation with the Alpha Omega Alpha. Supporting movements to end metrics that favor the White medical student, like the USMLE STEP scoring system, is another way. This list is by no means exhaustive; these are just examples of steps that remove barriers for students of color. There is a lot of work to be done to make medical education — particularly in the clinical realm — a safer space for our non-White students.
This car ride was a reminder that the first step is always the same: sit back and listen.
Image provided by author Nat Mulkey.