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Some say the lack of Black physicians is a pipeline problem, with too few Black people going to medical school. I say it’s a gaslighting problem.
The health of Black Americans lags behind that of white Americans, driven in part by the underrepresentation of Black physicians in the medical field. Numerous studies have found that patients of color experience better health care outcomes and higher satisfaction when cared for by racially and ethnically concordant physicians. Despite the existence of pipeline programs designed to increase the number of Black physicians, only 5% of all doctors identify as Black, in stark contrast to the number of Black individuals in America who account for 14% of the population. While there are multiple causes for this discrepancy, one reason is that Black trainees represent 20% of all residents dismissed from their training programs before completion.
The consequences of gaslighting, a form of emotional abuse that causes people to question their reality, may account for the outsized attrition seen among Black residents. I’ve been studying gaslighting among medical trainees. I’ve also experienced it.
The term gaslighting has been used to refer to a variety of techniques that invalidate a person’s experiences, and for Black physicians, this abuse has the potential to prey on insecurities such as imposter syndrome and stereotype threat. Gaslighting techniques include trivializing, where a person is led to believe that their feelings are not important, and diverting, where the abuser changes the subject by focusing on the person’s emotions or reactions. Examples include dismissing concerns about biased treatment and questioning one’s experience with inequity. In the workplace, gaslighting tactics may result in someone being unfairly penalized or fired.
Anyone can experience gaslighting, but Black physicians are especially familiar with the technique as one manifestation of implicit racial bias. Black medical students are subject to racially biased metrics such as standardized tests, Alpha Omega Alpha status, clerkship or rotation grades, and letters of recommendation, which are often presented as a means to assess one’s aptitude. Once the student falls short on these metrics, they may be told that they are not dedicated, focused, or resilient enough to withstand the rigors of medical training.
As residents, many Black trainees experience a yearslong cycle of gaslighting. This begins when a Black resident makes a mistake in medical knowledge or patient care. Her mistake is publicized among other trainees, faculty, and even ancillary health care team members. She is then more closely observed and scrutinized by her superiors, and unsurprisingly this leads to the identification of more errors. The rate of these errors is seemingly higher than that of her peers, but few raise the concern or even consider that this may be due to selective attention bias. (An instance in which the error rate may be similar among all residents but appears higher in those who are more closely observed.)
These mistakes are used to justify negative evaluations, and she is informed by program leadership that there is concern regarding her capacity to be a good physician. With her career at stake, she becomes terrified about making another mistake and goes to great lengths to recheck her work. Inevitably, this causes the appearance of uncertainty, inefficiency, and lack of autonomy. In surgical training, the stress of this environment may limit the trainee’s ability to demonstrate surgical skills and therefore further inhibit their progress to independent practice.
Meanwhile, residents who are not suffering the pressure of this emotional abuse are more likely to perform better. Their accomplishments are publicized and mistakes are downplayed as isolated, rare events. This may cause the Black resident to believe that her shortcomings are intrinsic qualities and cannot be changed. Residency becomes something she must “survive.” She tries to compensate by being a more likable team player, perhaps agreeing to unfavorable schedules or rotations, even though these may impact her ability to prepare for exams or evaluations. Eventually, her overall performance is evaluated at clinical competency committee meetings, a forum that could help identify gaslighting and curb implicit biases.
However, these committees are subject to groupthink. Once one attending begins to criticize the Black trainee and another agrees, dissenting faculty do not rise to the trainee’s defense in favor of maintaining solidarity. The resident may try to defend herself to faculty, asking them to consider whether implicit bias and racism play a role in her negative evaluations. These questions garner responses that trivialize or divert her feelings — more gaslighting tactics — which perpetuate the cycle. This insidious cycle happens at both the micro and systemic level, making it difficult to recognize, and even more difficult to link to, the implicit racial bias that initiated and perpetuated it.
As a urology trainee, I worked hard to be affable and available while providing excellent care for patients and assisting my co-residents and faculty. It seemed that no matter how hard I tried, I always fell short of the expectations of others. As a fellow, I trained under the J. Marion Sims Endowed Chairmanship at the University of Alabama at Birmingham. Sims was an Alabama surgeon who rose to fame for surgical techniques he developed through unethical experimentation on enslaved Black women in the 1840s. As a Black person, I found it painfully ironic that the program that trained me to provide quality and compassionate care for women also honored this brutal and racist surgeon. Furthermore, the inconsistency of elevating Sims as an example of professionalism, scholarship, and patient care while denying the implicit racial bias that negatively affected my evaluations of those same benchmarks was a form of gaslighting. As I’ve progressed in my career, I’ve learned that professionalism and clinical competency standards are inequitably applied when evaluating a Black physician, both during and after medical training.
Detecting and reversing the gaslighting of Black physicians is challenging. Traditional tactics, such as enlisting the support of others or reporting discriminatory or inequitable treatment to human resources, may not yield the expected outcomes for Black trainees. Trainees should keep a detailed written and dated record — such a record was instrumental in my success in fighting to have negative reports removed from my record at the state medical board. I also advise trainees to solicit written feedback from faculty at least once a month with specific examples of what they are doing to grow as clinicians and address any verbal feedback. However, this approach places the onus on the already burdened and burned-out trainee. Thus, gaslighting in medical education perpetuates due to ongoing implicit bias and the uneven power dynamics that force the trainee to remain silent about the abusive treatment or risk retaliation and invalidation.
Ultimately, the physicians who recruit and train residents are in the best position to end the cycle of gaslighting. These physicians are the gatekeepers to diversity in medicine because they have complete control over who enters and completes residency training. It is challenging to recognize implicit biases at the moment and how they affect one’s interactions with a Black trainee. Therefore, institutions can provide rater error training to faculty. Rater errors are errors in judgment that occur when an individual allows their own preexisting bias to affect the evaluation of another. Another strategy is to require faculty to list two to three examples that justify a less than average rating when completing trainee evaluations. Evaluators should also detail what actions they took to address any deficits with the trainee, and the impact.
Additionally, there should be an early, voiced acknowledgment of the risk of implicit bias at clinical competency meetings. Committee members should be encouraged to complete implicit bias training a few days before the meeting, and faculty should state two to three positive things about the trainee before voicing any criticisms. Only once those in a position of power and privilege begin to recognize and speak out against the gaslighting of Black physicians, and indeed all physicians from groups underrepresented in medicine, will meaningful increases in workforce diversity be achieved.
Shenelle N. Wilson is a urologist/urogynecologist and pelvic surgeon practicing in the metro Atlanta area and the founder and CEO of Urology Unbound, a nonprofit dedicated to the recruitment, retention and promotion of Black urologists and increased diversity in urology.