Original Article

Black Students' Perception of Belonging: A Focus Group Approach with Black Students at the Uniformed Services University of the Health Sciences

Monnique Johnson1, Witzard Seide2, Althea Green-Dixon3, Virginia Randall4

doi: http://dx.doi.org/10.5195/ijms.2021.877

Volume 9, Number 2: 124-128
Received 16 12 2020: Rev-request 11 02 2021: Rev-request 26 04 2021: Rev-recd 17 03 2021: Rev-recd 30 04 2021: Accepted 30 04 2021



Finding that enrollment of Underrepresented in Medicine students at the Uniformed Services University of the Health Sciences was considerably below the national average, researchers sought to understand the experiences of minority students. The goal is to develop an academic and social support structure that sustains and attracts students of diverse backgrounds and races.


Individual interviews of eight matriculated Black medical students and a focus group were conducted, with Institutional Review Board approval, to obtain feasible methodologies and implement change. Student's perspectives and experiences regarding their institution were investigated using qualitative thematic analysis.


The analysis revealed six themes from the individual interviews: Experience as a minority; Admission process; Difference in backgrounds; Curriculum culture; Diversity at the school; Military medicine. The overarching message from the students was “If you don't see yourself represented somewhere, it's hard to believe that you belong.” The focus group made four recommendations: Add a minority viewpoint to curriculum; Add textbooks that portray black skin; Collaborate with Historically Black Colleges and Universities; Increase recruitment of Black students and faculty.


It is hard for minority students to believe they belong in environments without the representation and infrastructure needed to support their unique needs. Implementing ideas, such as those described in this report, is an important step towards creating inclusion and equity.

Keywords: Medical students; Qualitative Research; Minority Groups; Undergraduate Medical Education; Social Perception (Source: MeSH-NLM).


Under-represented in medicine (URM) groups are defined as racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. According to the American Association of Medical Colleges, URM are: “Black/African American, Native American (American Indian, Alaskan Native or Native Hawaiian), Mexican American, and Mainland Puerto Rican”.1 URMs represent approximately 22% of students matriculating to allopathic medical schools across the nation.2 The F. Edward Hebert School of Medicine, Uniformed Services University (USU), lags behind its peers with a URM enrollment of 13.4%. Figure 1 shows little change in the percentage of URMs matriculating to USU over the past six years. Research has shown that Black students at predominantly white medical schools experience more stress than white students due to the perceived inadequacy of their academic preparation, poor interactions with faculty and classmates, lack of role models, environments insensitive to their cultural backgrounds, and implicit bias or racism.37

Figure 1

Percentage of URM at USU.

An extensive literature review shows a significant gap regarding first-hand accounts of the Black medical student experience, other than as depicted by Hadinger in 2017 where the URM perspective of the medical school admissions process was researched.8 Prior assessments of URM experiences were based on quantitative data, such as the 1980's study of Black medical students in North Carolina who identified their perceptions of their learning environment via a questionnaire.5 The lack of in-depth first-hand accounts of URM medical students led to our question: What are the experiences of URM students at USU? What can be done to mitigate negative experiences?


After Institutional Review Board approval, a recruitment email was sent to the 23 members of USU's Student National Medical Association (SNMA) chapter with eight responses (35% participation). Respondents all identified as Black, included male and female genders, and represented all four years of medical school. With consent from each participant, we conducted and recorded “virtual” interviews of individuals then subsequently, with a focus group. Interview and focus group questions are outlined in Table 1.

Table 1.

Interview and Focus group Questions

Individual Interview Questions Focus group questions
What is your definition of diversity? Are you satisfied with the diversity of your school? What are your thoughts on how the current curriculum addresses cultural sensitivity/awareness?
How would you describe your experience as a minority student at USU in your interactions with faculty and students? Can you tell me more about that? What thoughts and/or recommendations do you have to help increase cultural sensitivity/awareness in the curriculum?
How would you describe your experience as a minority student at USU with regards to the curriculum and your learning environment? Have you experienced racial bias? In what way? What resources do you feel the university has to support you as a URM? Support in what way?
How has your experience as a minority student at USU impacted your academic performance? Overall well being/morale-decision to pursue medicine? Military medicine? Which of the resources have you found helpful? What would you like to see implemented that would help support more students like you?
Would you say your experience in medical school as a URM is similar or different than that of your peers at USU? Explain. What ideas do you have to increase recruitment in URM in medicine? USU or Health Professional Scholarship Program?

Individual Interviews

One co-investigator (MJ), herself a Black woman medical student at USU, interviewed the 8 participants individually. There was an atmosphere of trust, shared language, and shared experiences. Trust allowed the students to speak candidly about issues they had previously kept private. The recorded interviews were transcribed by a professional transcription agency. MJ de-identified the interviews prior to sharing them with the other two investigators. Two co-investigators completed the analysis using thematic qualitative analysis.9,10 They independently used line-by-line coding with constant comparison. As they proceeded, the co-investigators discussed each line and code until coming to an agreement. They independently arranged the codes into themes and discussed the themes and their descriptions and implications until achieving consensus. NVivo 12 © (www.qrsinternational.com) was used to manage the data.

Focus Group

The focus group (seven of the eight students) was conducted by a second Black female faculty member (WS) in coordination with the medical student (MJ). Students were not deceived but were generally not aware of VR's presence (a White female faculty member) at the video meeting as her camera was not on. The questions were discussed candidly. The trust that was established in the interviews quickly became apparent in the focus group interactions. Consensus was established as the group discussed the themes one-by-one and found their experiences, opinions, and recommendations were nearly identical.

After a review of the focus group discussion, the authors proposed additional recommendations.


Individual Interviews

The analysis revealed six themes which are provided with samples of direct quotes from the interviews. Table 2 lists additional student quotations.

Table 2.

Additional quotes from the individual interview, along with their respective themes.

Theme Quotes (sic)
Experience as a minority
  • I come on campus and I don't see anybody that looks like me, maybe like one or two days a week, if I'm like on campus”
  • “there's just such a small number of minorities in medical school, especially our medical school… I don't know. I just think all of that stuff weighs on you, even if it's subconsciously,”
  • “the way the email was worded made me think that I was being told I failed like the entirety of the class. So I remember that day I was like depressed and I was in school and I couldn't talk to anyone. I was about to cry. And like, I just remember like the entire day hurt, my heart. And then I opened the whole e-mail. And I was just like, why would it tell me like this? And it turned out someone thought I was someone else again. And emailed me.”
  • “my experience in the beginning was a bit difficult because of getting called the wrong name a lot
  • “any time I had had multiple Black people in my group. I've been called one of the other black people multiple times.
  • “it's a little bit insulting just because, like, it means that the repertoire that we build, we're not actually building it. You're kind of packaging other black people and you're like, oh, yeah, black people.”
  • “you're minimizing by my existence, you know, and the work that I put, you know, is like well…not only did my existence get minimized but the person who I got confused with got minimized, too.
Admissions process
  • “Do something great. Like we got into medical school. But. You can still feel like we didn't really deserve it. … my MCAT score wasn't that high I know.”
  • “increasing diversity isn't just allowing more people in, but you have to have the infrastructure in place.”
  • “Because part of my opinion that part of increasing diversity isn't just allowing more people in, but you have to have the infrastructure in place”.
  • “So I think part of the exception that they made for me was because I'm diverse and I'm like considered a minority in many different ways. Looking back, I think that hurt me more than anything.”
  • “And so this significantly impacted my mental health and my wellbeing and constantly in the back of my head. I was just thinking to myself. Was I truly qualified or did they just want to like kind of kind of fill a quota”
Difference in Backgrounds
  • “I'm interested in minority health issues in that personally, as one of the rubs that I have with military medicine is because our constituents, our future constituents, they don't deal with the same things that minority, typical minority populations do… for me”
  • “it was hard for me to reach out to other students, to other students for help just because of that feeling of wanting of not wanting to be a burden on everyone else who's in the middle of studying for the same tests that you are and they're not struggling.”
  • “not really wanting to speak up and in certain conversations that are being had, because I don't feel like my voice will be heard because I guess that I have a different set of experiences, I think a little bit differently than everyone else.”
Curriculum culture
  • “I'm the one Black person and everyone's looking at me to like provide my black views on it. And sometimes that's hard. I don't know.”
  • “I've had multiple questions where there was nothing really to say that was sickle cell except for African-American.”
  • “I do think that there's times like during small groups that I don't feel like. I don't feel confident enough to speak up because I think a little bit differently than everyone
  • “it's not our job. We already have a stressful curriculum itself and I'm not going to sit there, and spend time teaching each one of these kids what it's like, to grow up without access to food and how food deserts work?”
Diversity at USU
  • “we would not be able to pull ourselves up by the bootstraps if we don't get no boot straps.
  • “I feel like if I were maybe not a minority, I would have more access to resources that people feel free to share that kind of stuff.”
  • I wish there were more minority students at our medical school, because I think that obviously from being a minority and being around others that share your common experiences, that can be helpful, almost like another support network. Instead of always trying to feel like you have to play two sides of the same coin and maybe not be your authentic self because you're constantly being judged or, you know, feel like you have to act a certain way.”
  • “it's just like stress I didn't ask for.”
Military medicine
  • “… like my first and second year made me start to question like, why am I even doing this? Like the whole purpose of people signing up to not just be in the military but also be a healthcare provider in the military is like a huge sacrifice in itself and the sacrifice for the people that you're also serving. And if they don't appreciate it. Then it's just like, why am I even wasting my time?”
  • “but if things continue the way they are, we're not really going to see changes
  • “I think a big issue of not having diversity, is if People don't know you as a person and they refuse to know you as the person. I'm not going to be able to get nowhere”

URM students experience intense imposter syndrome11 which does not abate. Imposter syndrome, while ubiquitous in students in higher education, is especially problematic among URM students, who often experience race-based imposter syndrome. Evidence of tokenism combines with low self-esteem to create an emotionally stressful situation in which URM students struggle, not because of academic difficulty, but because of being the only person of color in the classroom.

Minority students have difficulty relating to faculty, peers, as well as the Office of Student Affairs because of a lack of minority representation in areas that have been designated as “support” areas. Students are afraid to ask for help for fear of being labled “dumb” among classmates and faculty. Most have trouble adapting to USU's social life and are isolated. They feel out of place in the educational environment and feel the need to “code switch” (not use “Black English”; use only Standard English). They feel they must put on a fake persona to come to campus, which makes the experience emotionally draining and depressing. They do not feel the camaraderie that is displayed among their classmates and feel they must be overly cautious of how their words could be perceived. This theme was mentioned in seven of the eight interviews.

Seven of the eight students believe they were accepted to USU solely to fill a quota instead of having been selected based on merit. This was perpetuated when students shared examples of constantly being called the wrong name by peers and faculty or mistaken for “other Black people.”

Students highlighted the differences in their backgrounds, including not coming from prestigious schools, wealthy communities, or having affluent parents. Prior to attending medical school, URM students did not have similar resources such as tutors and role models as their non-minority peers. This theme was mentioned in six of eight interviews.

Students believe there is a racial bias in the curriculum. All students remarked that the race of most of the patients - either on written exams or patient interactions - was White and the way certain conditions looked on non-White races was only noted if someone specifically asked. Students felt that in the small group settings – where sensitive topics such as race were being discussed – the use of cookie-cutter answers often did not allow for open and honest discussion. This theme was mentioned in seven of eight interviews.

All eight students are dissatisfied with the diversity at USU regarding minority representation in both the pre-clerkship and clerkship curriculum.

Students express differences in their decision to pursue military medicine and the impact their USU experience made. Three students felt there was commonality because the military is a community that takes care of each other, while five felt the military was a vehicle for them to gain training then return to serve in their communities.

Focus Group Recommendations

Seven interviewees met with two researchers for additional discussions and provided recommendations to improve the USU learning environment. Their suggestions include updating the curriculum along with textbooks and resources, adding a minority viewpoint. Students feel it is important for educational material to reflect the diverse patient population, such as having textbooks that show how dermatologic conditions present on other than White skin. The focus group feels increasing recruitment of faculty, staff, as well as students must be a priority as USU is lacking Black faculty and staff. Students mentioned that the only resource available to support their URM-specific needs was the counseling center, but they were hesitant to visit the center because of the perceived lack of representation of minority counselors. In the interim, the focus group recommends USU collaborate with local Historically Black Colleges and Universities (HBCU) to obtain advice/assistance on issues related to diversity and cultural competency.


“If you don't see yourself represented somewhere it's hard to believe that you belong” was alluded to by all participants and summarizes the themes found. Students need to see themselves represented among their peers, faculty, and curriculum. Unfortunately, the perceived lack of diversity in these areas manifested as feelings of tokenism. These URMs attending USU experience minority-specific imposter syndrome and perceived racial bias in the curriculum. They feel lonely and out of place, with limited connection to their non-minority peers, based on their goals to serve in underrepresented communities. These sentiments led to the recommendations from the focus group which embody their need: to feel welcome in their learning environment, create a similar environment for other URM, and for their peers and faculty to be aware of their perceptions of isolation and being unwelcome.

Researchers' Recommendations

The researchers provided five additional recommendations based on their subject-matter expertise and engagement in previous programs. First - URM students require a program that provides academic and social support. Second - faculty/student-led forums surrounding issues of race and racism, followed by action, must continue. Third - design a Racism in Medicine course. Fourth - expand mentorship opportunities for pre-medical audiences. Fifth - design a pipeline program for pre-medical students who have potential but do not meet USU's admission requirements.

Integrating a minority viewpoint to the curriculum and adding texts and resources that demonstrate the minority experience can increase the likelihood of improved relationships and later patient–physician concordance.1216 Collaboration with local HBCUs and increased recruitment of Black students, faculty, and staff will provide students more sense of belonging and contribute to the critical mass that is needed to make meaningful change.17,18 Programs, such as the medical school pipelines at Wayne State University as well as Southern Illinois University Schools of Medicine, have been successful in matriculating and supporting diverse students.19,20 A cascading mentorship program can promote an inclusive climate by providing academic and social support to students at different levels of education and from a variety of backgrounds.21,22 These interactions highlight the significant roles medical school personnel have as role models in helping to diversify the medical profession.23

USU is not unique among U.S. medical schools that are struggling to recruit and retain a diverse student body. Medical school leaders across the nation are developing and implementing innovative solutions to this challenge.1722 With the transition to a virtual era during the pandemic, collaborating with other schools is more accessible than ever. Collaborations could start by simply having guest facilitators moderate/teach a Zoom (distance learning) class from anywhere in the world. Thus, this study's results are certainly generalizable to other medical and graduate schools that face similar challenges.


This study was conducted at a military medical school - the only one of its kind in the U.S. The experiences and feelings of the participants that responded may be different from the general population of medical students in the US. Self-selection could have created a population of participants whose opinions and experiences differed from other SNMA members who did not participate. Further comparative research to evaluate students' perspectives, to include comparative sampling, would be useful.


It is difficult for minority students to believe they belong in an environment without the representation and infrastructure needed to support their specific needs. Students experience intense imposter syndrome, feel lonely, out of place, exhausted by the “minority tax” and “don't know how to navigate the system and don't feel welcome.”24 Implementing programs and ideas like those found in this report will be a step towards creating inclusion and equity.

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization: MJ WS, VR. Data Curation: MJ, AG, VR. Formal Analysis: MJ, AG, VR. Investigation: MJ, WS, AG. Methodology: MJ, WS, VR. Project Administration: MJ. Resources: MJ, VR. Supervision: WS, AG, VR. Visualization, Writing – Original Draft, & Writing: Review & Editing: MJ, WS, AG, VR.


This work was completed under USU IRB oversight through Protocol # 925769, with support from the USU Office of Research through the Capstone Program. The views expressed are those of the authors and do not represent the official position of the Department of Defense or the Uniformed Services University.


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Monnique Johnson, 1 2d Lt Monnique Johnson, USAF, MSC, Class of 2023, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, United States

Witzard Seide, 2 CDR Witzard Seide, MD, USPHS, Clinical Associate Professor of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, United States

Althea Green-Dixon, 3 PhD, CSM, USA (ret), Director of Recruitment, Assistant Professor of Military Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, United States

Virginia Randall, 4 MD MPH, COL, MC, USA (ret), Associate Professor of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, United States

About the Author: 2d Lt Monnique Johnson is currently a 2nd year medical student at the F. Edward Hebert School of Medicine. She is a member of the Student National Medical Association, and peer leader for the school's inaugural Racism in Medicine course which she helped design and champion.

Correspondence: 2d Lt Monnique Johnson, Address: 4301 Jones Bridge Road, Bethesda, MD 20814. Email: monnique.johnson@usuhs.edu

Student Editors: Adam Urback Student Editors: Brandon Belbeck Copyeditor: Benjamin Liu Proofreader: Adnan Mujanovic Layout Editor: Annora Ai-Wei Kumar

Cite as: Johnson M, Seide W, Green-Dixon A, Randall V. Black Students' Perception of Belonging: A Focus Group Approach with Black Students at the Uniformed Services University of the Health Sciences. Int J Med Students. 2021 May-Jun;9(2):124-8.

Copyright © 2021 Monnique Johnson, Witzard Seide, Althea Green-Dixon, Virginia Randall

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 9, NUMBER 2, May-June 2021