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

ABSTRACT

Background:

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.

Methods:

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.

Results:

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.

Conclusion:

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).

Introduction

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.^3–7

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?

Methods

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.

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.

Results

Individual Interviews

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

• Experience as minority: “The only time we see [like] black people is [like] the people who are serving us lunch or [like] people who are [like] janitorial service.” (sic)

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.

• Admissions process: “I only got in because, you know, they were looking for a quota.” (sic)

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.”

• Difference in backgrounds: “my interest lies more in those populations that have to deal with food deserts or who go to disadvantaged homes or who systematically grow up with fear of physicians.” (sic)

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.

• Curriculum culture: “we need a curriculum, we need textbooks, we need lecture materials that identify African-American skin…because that's what we're treating. We're not just gonna have a white patient all the same all the time.” (sic)

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.

• Diversity at USU: “It's hard to think that a school cares about you if they don't have many of you in the school” (sic)

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

• Military medicine: “my decision to continue to pursue military medicine is definitely brought about hesitancy” (sic)

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.

Discussion

“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.^12–16 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.^17–22 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.

Limitations

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.

Conclusion

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.

Acknowledgments

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 2^nd 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