The goal of neonatal–perinatal training is to expose and prepare trainees for a successful career in academic medicine as defined by publication of peer-reviewed journals, securing of grants, membership in national societies and visiting professorships. These activities denote peer recognition and lead to promotion and tenure. Other important factors in a successful career are effective teaching and mentoring as well as developing models of clinical excellence. Obviously, the ultimate career goal is personal satisfaction. For underrepresented minority physicians (URM), these goals are sometimes more daunting and difficult to achieve. This paper will attempt to define the reasons why this may be the case.
The last US census demonstrates that 32.6% of the population is from a minority group.1 This segment of the population is often overrepresented when it comes to debilitating diseases such as diabetes, cancer2 and conditions relating to prematurity,3 yet only 4.9% of all medical school faculty are underrepresented minorities. Furthermore, in the United States, the pediatric population is becoming increasingly diverse yet the workforce is not.4 Despite the fact that in recent years, a larger proportion of minority students have matriculated from high school, these students only comprise 13% of the BS degrees and 7% of the PhD degrees5 and the percentage of URM accepted into medical school has been declining in the last 6 years6 – demonstrating clearly that the pipeline is leaking.7 Recently, the term underrepresented in medicine was coined to define faculty that are from racial and ethnic groups that are underrepresented in the medical population relative to their numbers in the general population.8 Corroborating this, African-Americans constitute 3% of the medical school faculty and only 1.2% of the professors of the medical school, whereas white subjects represent 81.3% of the medical school faculty and 89.4% of the professors.6 This suggests that the underrepresented minorities are not only less represented in medicine, but they are also less likely to be promoted in academic rank. Using this same criterion of underrepresented in medicine, one would suggest that Asians, who represent 12.6% of the medical population but only 4% of the general population, should not be considered.6 However, upon closer look, in the medical school, Asians are overrepresented at the more junior ranks and underrepresented at the senior ranks, as are the other minority groups.6 Despite this gloomy picture, there is good news in that over the last 7 years, an increasing number of URM have chosen pediatric residency programs and have expressed increased satisfaction with their preparation for fellowship training.9 However, they also indicate that they are burdened with increasing debt. For example, whereas 52% of non-URM report being debt free after medical school, only 25% of URM do.6 No statistics exist to determine the number of URM in neonatal and perinatal medicine, but these numbers are likely to be even smaller than those for medicine or pediatrics as a whole.
In view of the difficulties in finding URM in medicine, why bother to train URM scientists? A diverse workforce goes beyond any societal and moral considerations. It is clear that URM are more likely to address minority health issues in their career objectives, and also serve the underserved patients in large urban areas.6, 10, 11 They are also important role models for future generations and they provide a diverse perspective, which allows for growth within the institution.
Factors that influence the scarcity of underrepresented minority trainees
Why is there a dearth of URM trainees and an even greater absence of URM in academic careers? Perhaps some of the following factors may play a role:
lack of minority role models,
lack of mentor support,
lack of networking opportunities,
academic and service goals that may compete,
lack of financial support.
As to the lack of minority role models, this obviously stems from the lack of URM in academic medicine. Lack of mentor support may also result from the difficulty that mentors have of seeing eye-to-eye with a URM unless they are of similar cultural backgrounds. Therefore, communication may be more challenging owing to lack of common experiences. Assumptions are often made on both sides and there may be instances of subtle and no so subtle discrimination or prejudice. Owing to the low number of URM, networking opportunities are often lacking as well because the group is so scarcely represented in the faculty. This leads to continued isolation.
Suggesting that academic and service goals may compete stems from the fact that URM are more likely to have added pressures to care for people of their own race and to serve on committees because they fit the requirements for diversity of the group. In fact, more URM serve the clinical needs of underserved populations. It is also important to serve at other levels that may enhance URM visibility and leadership. This type of service may ultimately have a larger impact on underserved populations in the end.
Institutional difficulties stem from cultural differences that could impede the success of URM. Although cultural diversity is often discussed and sought after in academic institutions, it is not well understood. Training programs tend to seek individuals that are from diverse backgrounds but prefer that they behave exactly like the majority. This provides a comfort zone based on experiencing the familiar. Individuals who come from different cultures often do not behave like the majority and have more difficulties understanding the system. For example, traits that may be considered desirable by the training program, such as assertiveness, self-assuredness and speaking up frequently, are not necessarily the natural characteristics of certain cultures, thereby rendering the members of that group undesirable in the selection process. Differences in hairstyles and manner of dress often make many people uncomfortable. It appears that the only way to be accepted is to truly ‘fit in’ by having white characteristics in a black or brown exterior.
As to financial support, URM, as well as the majority trainees, desire to get to their career goals without incurring further debt. Low-paying positions are the norm in post-residency training. Underrepresented minorities often come from less-affluent backgrounds and may feel added pressures to earn money fast.6
There are other intangible factors that also present barriers to successful academic careers for URM:
fear of loss of identity.
Visible minorities are often more likely to be held up to higher standards. If one white person fails, the whole group is not damned, whereas this is the case for URM. This leads to unfair biases and near impossible standards to uphold, especially as URM may be less well prepared for a career in research owing to lack of exposure during the earlier phases of their training.
Stereotypical assumptions may come from the lack of a cultural understanding. Negative characteristics are often held as the truth, and this is often demoralizing for the URM.
Because there are few people with similar backgrounds and characteristics, there is often a sense of isolation. This makes it very difficult to feel supported and to commiserate with a peer group when times are difficult.
As discussed above, in many instances, cultural differences are not well tolerated; therefore, it does not seem feasible or safe to continue to exhibit one's ethnic and cultural traits. This would certainly lead to feelings of isolation and loss of morale.
It is important to increase the pipeline of URM by allowing for early exposure to research. There are many such opportunities offered by the National Institutes of Health (NIH).12 Minority Access to Research Careers is one such program. Minority Travel Award Programs facilitate participation at conferences. Opportunities exist to obtain supplements from an existing RO1. Other training opportunities exist through Centers of Excellence funded by the NIH. The Health Careers Opportunities Programs also provide early research and clinical URM exposure to college students.
It is also important to provide examples of success and rewards of an academic career. Underrepresented minority trainees do not often get to hear the rewards and pleasures of a career in academic medicine. They see harried and overcommitted mentors with limited financial rewards. We must do better at voicing why we made the choices that we made and what are the highlights of the academic life. These are many, including varied daily activities, opportunities to network and share research ideas at national meetings, exposure to trainees, the personal satisfaction of scientific discovery, as well as the exposure to cutting edge medicine.
Financial incentives are needed to allow for postponement of more lucrative careers. Currently, there are funds available to defer or pay off loans,12 thereby removing the pressure to go into practice to quickly earn a living. Other opportunities should be provided to encourage mentors to train URM. Mentors often have limited resources to pay for additional personnel or to subsidize the cost of an additional project. This financial incentive could be in the form of a supplement to a grant or a credit for time spent, thereby reducing the percent effort that needs to be funded by grants. This would require the collaboration of the granting institution and the academic institution. Programs that provide a stipend for the mentee and the mentor, as well as some support for the laboratory, are very helpful.
There are multiple networking opportunities for URM that allow for contact with peers and with mentors from other institutions. Specific meetings, such as the National Medical Association (NMA), the American Academy of Pediatrics or the Pediatric Academic Societies annual meetings, offer an opportunity for both social and career-related gatherings. Identifying role models is often more challenging if one is trying to find someone of the same race because of the low numbers of URM on the campus. Therefore, it is important to get exposure at minority meetings such as the NMA, or at gatherings targeted for URM at national meetings so as to meet senior URM who have achieved successful careers in our field.
The process of mentoring is very complex and is ‘a dance for two.’ The mentor needs to provide clear expectations for mentees. Mentors provide leadership and guidance, but they should also provide prospective counseling, education and monitoring of career progress. They should also facilitate participation at meetings and critique the trainee's work, as well as provide rewards whenever possible. A seasoned mentor enhances the likelihood of critical introductions to prospective collaborators and employees, thereby decreasing the isolation of a vulnerable group of prospective faculty. The successful mentee needs to seek help from the mentor, to meet deadlines that are part of the career plan, and also to follow advice. At times, this may be more challenging if he/she does not agree with the advice. Multiple mentors could provide varied points of view. However, one person is likely to have a more significant role in the mentoring relationship. The successful mentee also needs to learn to trust and to accept critiques. Trust is a difficult concept, especially when there are cultural differences and concerns that one is misunderstood. However, there needs to be faith that the mentor will be supportive and trustworthy. If this is not the case, the mentee needs to have an opportunity to air concerns to the program director, division chief or another ombudsperson.
In order to see more successful URM trainees in neonatal–perinatal medicine, it will be important to work prospectively to provide early exposure opportunities to students from high school to fellowship. Also, early exposure dictates a need for longitudinal support and a continued sense of encouragement throughout the training experience. Financial support is useful to allow for deferring the immediate gratification of a large salary provided by private practice. Also, financial support for the mentor allows for the willingness to train mentees or to take on an additional project associated with the mentee joining the lab. Networking opportunities need to be frequent to provide for additional support, visibility, exposure to senior physicians of the same race or same culture. Lastly, establishing a database to define the number of underrepresented minorities in neonatal–perinatal medicine would be important in order to monitor progress and success of any initiatives geared at increasing the numbers of URM.
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Dennery, P. Training and retaining of underrepresented minority physician scientists – an African-American perspective: NICHD AAP workshop on research in neonatal and perinatal medicine. J Perinatol 26, S46–S48 (2006). https://doi.org/10.1038/sj.jp.7211525
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