A Tide to Raise All Boats--Structured Mentorship As a Race-neutral Option for Happier and More Diverse Residents.

Ms. Risa L. Wong, BS, and her coauthors examined the influence of race on residency experience as self-reported by 4,339 general surgery trainees.1 The authors found Black residents were less likely to be happy (62% vs. 74%) and feel they “fit in well” (74% vs. 86%) with their training program than White residents. This study is especially timely in light of the Nation’s changing demographics. By the year 2050, the United States will no longer have a majority race.2 In contrast, the composition of the surgical workforce remains a far cry from what could be reasonably considered “representative” of the population at large. Discordance between the demographics of the general population and of the physician workforce have deleterious effects on both the resident-attending and the physician-patient relationship. As surgical training depends upon a quasi-master/apprentice relationship, one cannot help but wonder if the disparate experience of Black and White residents is at least partly explained by the lack of minority faculty. The negative experience of many Black trainees perpetuates this deficit through two mechanisms. First, it increases the potential for attrition. As with Black residents, trainees who eventually leave their program also report being unhappy and not “fitting in.”3 Second, Black residency graduates do not enter academia at the same rate as non-Black graduates. In fact, the disparity in faculty demographics is even wider than for physicians as a whole. African-Americans represent 7% of medical school graduates, 5% of surgery residents, but only 3% of surgical faculty and less than 2% of tenured professors of surgery. In contrast, White physicians represent only 64% of surgical residents but 86% of tenured professors.4 Concerning the physician-patient relationship, research has found patient perceptions of quality are influenced by provider race. On the physician side of the equation, studies have show that White physicians have implicit preference for White patients even in the absence of any explicitly articulated biases.5 This phenomenon has even been documented in medical students.6 On the patient side, nearly 25% of Black patients acknowledge explicitly considering race when choosing a provider. Further, these patients are more than twice as likely to rate care received by Black physicians as “excellent” than care received by White providers.7,8 African-American’s well-documented mistrust of the American healthcare system may, at least in part, explain these findings. This mistrust manifests in a variety of ways including the tendency for late stage presentation seen in African-Americans with lung cancer or our lack of participation in randomized controlled trials.9,10 Yet, until there is improved provider diversity, it is unlikely these disparities will improve. Unfortunately, the current sociopolitical climate makes it unreasonable to expect any significant change in workforce demographics without some form of intercession. The challenge for medical educations is to utilize a race-neutral mechanism. For example, in its latest term, the United States Supreme Court has reconsidered raced-based admissions policies for the second time in less than 10 years. Regardless of the result, residencies may understandably be hesitant to support programs that could be construed as affirmative action. Nonetheless, there are race-neutral strategies that may serve as a tide to raise all boats. For instance, organized longitudinal mentoring programs may facilitate increased representation for underrepresented minorities while increased satisfaction for all residents. Sullivan et al. demonstrated that residents who do not socialize with attendings are 3x more likely to experience dissatisfaction than those who do.11 Similarly, there are numerous studies finding the positive impact of personal mentorship on many aspects of career success. Even for undergraduate college students, structured outreach and mentorship by surgeons has guided students toward a career in surgery.12 We hope residencies will commitment to structured mentorship and early outreach as race-neutral mechanisms to achieving a less disparate training environment.