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Bloom Blog

Black med students bump up against 'white man's club' in surgical training

By Louise Kinross

Last year a groundbreaking study found that Black people in American counties with more Black primary-care doctors live longer. Yet research shows that Black medical students have higher rates of burnout and attrition than white students.

Now a new study explores why so few Black medical students in Canada become surgeons.

Scientists from St. Michael’s Hospital and the University of Toronto's medical school interviewed 18 Black medical students and nine Black surgical residents—most in Ontario medical schools—in the qualitative study. It was published in the Journal of the American College of Surgeons.

In 2023, 56 per cent of Canadian surgeons were white men, the study notes. “…it’s like a white man’s club,” one Black female medical student said in the paper.

Lack of Black mentors in medical school and postgraduate training was a major stumbling block for students who wanted to become surgeons. “For many of the students, their experience of being the only Black learner in their respective programs contributed to their isolation, anxiety, and depression,” the authors wrote. “Black medical students struggled with the idea of being the only Black surgical resident or staff in their institutions and the possible impact to their mental wellbeing.”

Edgar Akuffo-Addo is a fourth-year medical student at the University of Toronto and author on the paper. "The initial idea came from one surgeon, Dr. Jory Simpson at St. Michael's, who coordinates our surgery rotations in third year," Edgar says. "He reached out to the Black Medical Students' Association at U of T to ask why Black students weren't represented when it came to surgical residencies."

Edgar says the study found that an unsafe work environment was the main barrier. "Coming in to this project I thought the financial cost and having to train for five to six years might be major barriers. Surprisingly, that wasn't the case. We found it was the lack of a safe environment when people did their rotations that was the main issue. Some students had supportive mentors who weren't Black but were culturally sensitive, but others had very negative experiences."

For example, a hijab-wearing student was yelled at about her hijab not being sterile for the operating room. "Usually when you go to the OR, all of the gear you need to wear is right at the door, so you grab it quickly and you're ready to get on the case," Edgar says. "But this student who needed a special head covering was made to go and find the charge nurse each time, and ask for her covering. That meant she would show up five minutes late to surgery, which looked tardy, and it negatively impacted her evaluation. It didn't make sense that her head covering wasn't put right at the door with all the others."  

A “jock culture” was alienating, the study found, especially to Black females and immigrants. “Participants who did not share in this culture felt excluded in the operating room when these conversations happened… A Black female surgical resident shared an instance where all the male residents in her program organized a cottage trip and failed to invite her.”

Lack of mentorship and social capital earlier on in a student’s training made it more difficult to land research opportunities, and that research experience was weighted heavily for admission to surgical residencies. Black medical students were more likely to engage in advocacy work in the community, the authors found, but that work wasn’t recognized.

Racist microaggressions contributed to an unsafe environment for Black learners at all levels.

Black students considering surgery were discouraged by supervisors, who suggested they didn’t have the stamina for it. One student reported that his calm presence was interpreted by nurses and staff as laziness, while the same behaviour in white male students was described as “working well under pressure.”

Another reported being ‘over-policed.’ “If I would do something that was neutral, something neither good nor bad, people you wouldn’t even expect, like nurses or physiotherapists, [would] report it to my program director that I did something wrong.” Black residents generally found themselves monitored and their skills criticized in a way that didn’t apply to their non-Black peers.

Racist comments from patients were reported, and staff failed to condemn them.

Because surgical subspecialties are male-dominated, female students considering this path didn’t believe it would accommodate pregnancy and a work/life balance.

Surgical culture was one of perfection, overwork and inhumane demands, participants said. Residents were expected to work continuously and “ignore the urge to eat or void,” the authors wrote.

Among surgeons, “there is some level of arrogance, some God-like complexes, in some cases real tunnel vision and inability to see beyond the task…and a very severe hierarchy,” one participant said. This was seen to create a hostile work environment.

Sleep deprivation because residents were expected to work beyond maximum shift lengths and call frequencies deterred some students from pursuing surgical training. “I think most of the world has misconceptions about surgery,” one participant said. “They don’t know the person doing the surgery probably hasn’t slept in 32 hours” and is “running on caffeine and adrenaline.”

The authors conclude: “Except for a few surgical programs, medical schools across Canada do not offer a safe space for Black students and trainees to access and complete surgical training.”

Recommendations to create training environments that attract and support Black residents include: a commitment to change from senior faculty and staff; implicit-bias training for faculty and staff; a formal admission stream for Black learners; changes to the admission process so that life experience and advocacy work is recognized; and creation of a national registry of Black surgeons and allies willing to mentor students.

Edgar, who just matched into dermatology at U of T, says a working group is already being formed to work on implementation. "Across Canadian medical schools, usually one takes the lead, and if there's evidence, the others follow," he says. "U of T created an admission pathway for Black students and 21 of us enrolled in 2020. Almost all of us have graduated, so they've seen the evidence that this thing works. Now we need to find solutions and make things better once people are in the program. Hopefully we can make changes at U of T, create the evidence that this works, and others will replicate it."

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