The Value of Cultural Representation in Medicine: Personal Reflections of Medical Students

Health disparities present an ongoing threat to Americans, with marginalized communities disproportionately shouldering the burden of adverse health outcomes. Black and Hispanic communities have higher rates of type 2 diabetes mellitus with significant disparities in care metrics such as hemoglobin A1C monitoring and screening eye exams. ¹ Black women are at least three times more likely to die from a pregnancy-related cause than White women. ² These are just a few of the inequities that present ongoing challenges for the American medical system. Addressing health disparities will require multifaceted solutions. One proposed approach is to increase diversity in the health care workforce to more closely approximate the general population. ³

Diversity in the workforce has been shown to improve outcomes in a multitude of settings, and health care is no exception. ⁴ For example, a growing body of literature suggests that racial concordance between physician and patient results in improved therapeutic relationships and lower health care costs among minority patients. ⁵ Diversity also seems to contribute to motivation for service, because physicians who identify with historically marginalized communities are more likely to provide care for the underserved. ^{6, 7, 8} These data suggest that increasing the number of minority physicians could aid in improving health care access and outcomes. ⁶ Diversifying the physician workforce is theorized not only to directly bolster the care provided to minority populations, but also impacts training. The presence of more diverse cohorts within medical schools during medical training is associated with improved self-assessed readiness, across all students, to care for diverse patient populations. ⁷

Despite these known benefits, the physician workforce has been slow to diversify. Only 10.8% of physicians identify as African American or Hispanic, while only 14.6% of medical school applicants identify with these populations. ⁹ With roughly 36.3% of the US population identifying as African American and Hispanic, a clear mismatch exists between the demographics of physicians and the patients for whom they care. ¹⁰ This discrepancy lends the title of underrepresented in medicine (URiM) to those identifying in these groups, among other backgrounds.

Studies exploring the failure of the medical field to diversify have identified myriad challenges. URiM premedical students affirm challenges of finding a mentor, meeting financial obligations (debt burden and financial costs of medical school), and overcoming further unique challenges of low role model representation at historically predominantly White institutions. ¹¹ Often the issues that premedical URiMs face permeate into their future medical school experiences. African American and Hispanic identifying medical students make up 13.3% of matriculating medical school classes, with only 11.5% of medical school graduates identifying within these communities. ⁹ Where did those students who did not graduate go? Some answers perhaps may be found in the challenges faced by matriculated URiM students, such as stereotype threat and insufficient mentorship, particularly connecting with mentors from underrepresented backgrounds. ¹² These challenges have perpetuated further inequities among URiM students.

Now, more than ever, efforts to increase the number of physicians from historically underrepresented backgrounds have come under attack. Most recently, the federal dismantling of diversity, equity, and inclusion (DEI) programs and Supreme Court decisions banning affirmative action in educational settings represent significant setbacks in efforts to diversify the physician workforce. ^{13, 14} Recognizing the value of diversity requires lifting the disenfranchised voices of overlooked colleagues and continuing to push for increased equity. The perspectives of URiM trainees and colleagues offer critical insights into the challenges faced. Their frame of reference encourages the implementation of strategies from a diverse viewpoint that may lead to improving health outcomes for all. 

The following narrative accounts illustrate the perspectives of two medical students along their pathways in medicine. For many medical students, the journey to medicine begins with personal or familial experiences of poor accessibility to health care. ¹⁵ While this article is nowhere near inclusive of the experiences of all students considered URiM, the authors of this paper implore readers to reflect on recurring themes among URiM experiences, the various avenues to medicine, and the roadblocks of medical education as narrated here. The following author narratives discuss the importance of recruiting physicians who showcase cultural humility in medical specialties and the value of mentorship in navigating retention levels as medical students.

My family story starts in Jesus María, Jalisco, Mexico, under extreme poverty conditions, with limited access to health care, insurance, transportation, and other important social support systems. My late family sought refuge by moving north for better opportunities. Walking on foot, they attempted to carry themselves to Tijuana, a small town in Baja California, Mexico, next to the US–Mexican border. This journey represented a 1,466-mile (about half the width of the United States) or a 531-hour walk through the desert. We lost my great-grandfather during this relocation; he was found deceased along the route he traveled on foot from Mexico to the United States in search of better health care. His wife continued her journey and made it to Tijuana. They were looking for something better—better care, better conditions, and a better life.

One generation later, my paternal grandmother, Regina, worked in a flower shop. I was too young to witness her beautiful arrangement-making skills before she passed. My dad worked in the flower shop alongside her, his siblings, and his tias y tios (aunts and uncles). I am lucky enough to see my grandmother’s work shine through my dad’s flower arrangements. His mother was declared legally blind in her 20s due to early onset glaucoma, diagnosed with diabetes in her 40s, and ultimately needed dialysis toward the end of her life. She passed away at the young age of 63 due to unknown cardiac complications. Her entire life, from the 1940s to the 2000s, she was living well below the poverty line, and her reliance on government-provided health care made treatment a burden to figure out. Her basic health care needs had to be approved through lengthy processes. Fighting for quality care and finding advocates who understood her condition was next to impossible. Due to his upbringing, my father joined the Army to open more opportunities for his family.

My maternal grandmother, Elaine, started smoking cigarettes at the age of 12. Her chronic exposure to tobacco caused significant lung damage, resulting in emphysema. In addition to this, she suffered from diabetes. Her diagnosis came late as she did not have routine primary care. Medications were not available to her due to costs and limited access to medical care. One night she presented to the town emergency department for shortness of breath. The emergency room physicians diagnosed her with pneumonia and COPD exacerbation. She refused medical care due to the financial burden. She returned home and passed overnight at the young age of 63. Her time was cut short due to limited knowledge and access. My mother and aunt pushed to find answers as to why she was sent home in her condition, only to find out that her condition could have been prevented with education about her resources and a little advocacy. Although she qualified for Medicaid, she was not aware of the resources she had access to in this program. She always despised going to the hospital, because she had watched her mother lose everything to medical bills and lack of quality care. This is why it is crucially important to push for diverse representation across all patient populations. Physicians who understand and will fight for patients of underrepresented populations are necessary for competent care. If patients can hike across miles of terrain for an opportunity to make it to a culturally competent physician, we can ensure we are prepared for when they get to us. That is our job.

As a first-generation medical student, it is my desire to strive for this advocacy across the entire medical field. Increasing the representation of underrepresented minorities in medicine can help eliminate these detrimental gaps in the health care system. My family’s experience with health care would have looked extremely different if they had a physician with a personal understanding of their circumstances and the desire to ensure they had the resources they needed. I often wonder how different my grandparents’ health outcomes might have been if, while living in the United States, they had access to a physician who could truly empathize with their lived experiences. Their struggles with inadequate health care access in this country strongly influenced my decision to become a physician. I hope to advocate for underserved populations who face similar barriers. Their stories reflect the difficulties that many Hispanic and other minority families continue to face when navigating health care access today, such as financial burdens and medical mistrust. Although the road to equal opportunity may never be perfect, we can start by filling in the gaps of the broken pathway to medical access for our patients. We can start these repairs by creating culturally and socially attuned health care teams.

As soon as I started medical school, I made average to poor academic progress. I ended up on academic probation by the end of my first semester. I spent my M1 year of medical school terrified of having to repeat the academic year because of my poor performance. While I was never a shy learner, struggling from the very beginning of the school year shattered my confidence in my academic capabilities. I considered ending my journey toward medicine altogether because I doubted my ability to become a great physician.

While I know that my experience is not unique, as imposter syndrome may affect students of all backgrounds, I found it particularly troubling seeing that many of my peers of minoritized backgrounds were facing similar struggles. This made me wonder about how imposter syndrome can impact a student’s academic performance and confidence. I kept questioning what other students were doing in their study habits that I was not, or why my grades did not reflect my efforts. I felt like I was studying the wrong concept; or during the exam, I would forget the key details that I needed to get an answer correct. With my confidence at an all-time low, I picked up the phone and contacted a former Dean of Multicultural Affairs at my institution, Dr Railey, whom I had met in passing. He encouraged me at a critical time in my academic career, making me believe that I was capable. Dr Railey provided reassurance and reminded me to fully utilize the resources available to me. Most importantly, he helped me reframe my struggles, not as a reflection of my intellectual capability but as the result of systemic barriers and internalized biases that often undermine students from underrepresented backgrounds. His support was pivotal in helping me progress through my medical education with confidence and clarity.

Mentorship to me means forming quality relationships with people from various backgrounds who are uplifting. If I had not picked up the phone and called that day, I am unsure how I would have progressed academically. While all students benefit from mentorship, I would arguably say that minority students have greater benefit from quality mentorship because more societal forces negatively impact minority students in medical school. The encouragement I received during my preclinical years did not eradicate the incessant feeling that I was underperforming my peers. The imposter syndrome persists even during my clerkship years as a third-year medical student, especially when not many people in medicine look like me. Seeing health care disparities firsthand as a clinical student highlighted the importance of mentorship in medicine and in advocating for improved outcomes for underserved patients. 

My interest in preventative health and continuity of care was piqued during my family medicine clerkship. Patients I encountered during my family medicine rotation who may have said “no” to medical students in the past said “yes” to me because of our shared ethnic and cultural background. I will never forget my patient who had not seen a doctor in 6 years, with a laundry list of health concerns. She was African American and expressed that she was happy to have a medical student of color. During her appointment, we discussed barriers to accessing care, her health concerns, and smoking cessation. I saw the patient again during her 4-week follow-up appointment. She recalled our prior encounter and was more engaged and proactive about her health.

I want to emphasize the need to recruit a diverse physician workforce that reflects the demographics of the United States. Recruiting underrepresented minorities in medicine means nothing if we are not being retained in our academic institutions. This can be targeted from different angles, such as programming initiatives, but retention success begins with meeting each student’s individual needs. Finding ways to nourish the important relationship that comes with mentorship made a pivotal difference in my medical journey.

A widespread assumption exists that the recruitment of minorities into different roles is sufficient. Academic and professional support is overlooked as a vital aspect of the medical curriculum. In this section, the same two students grapple with how to recruit URiM students while ensuring that they have sufficient academic and professional support.

As a first-generation Latina medical student, navigating the medical school application process was a challenge. I grew up in an area without a large footprint of Hispanic physicians and mentors. When choosing a medical school, finding a program with female and minority representation in their physicians and faculty was a substantial component of my decision process. As a student-physician interested in a historically male-dominated field of surgery, I knew that having female surgical mentors was crucial in ensuring my success throughout medical school and subsequent residency applications to general surgery. These mentors can give me the tools and advice to push me through a competitive field and accomplish my goals as a future female surgeon. The lack of diverse representation in this field adds barriers to achieving my goals without effective mentors. When deciding on a school, I knew I needed a place where I could feel at home and supported in my experiences with medicine, whether that be in my community or personally with my family, and my “why” for becoming a physician. I knew these mentors and opportunities would allow me the chance to make a difference in underrepresented medicine access and the ability to pave a pathway for incoming underrepresented students. Through student affinity groups, I have been able to provide resources to underclassmen and advice on navigating the milestones of medical school. I found a community where I can seek mentors and be a mentor all in one place.

Paving the way as a Liberian-American medical student poses various challenges. I have found it difficult to pave the way for other underrepresented students when I have not reached the ultimate destination of becoming a practicing physician in the United States. What I can do, at this stage of my medical education career, is offer advice to the premedical students who seek guidance and want to be in the position that I am fortunate to be in—a third-year medical student. I would have been lost without other URiM medical students, who spent countless hours helping me achieve acceptance into medical school when I was once a premedical student aspiring to become a medical student and ultimately, a physician. Reaching a privileged position comes with a deeper sense of responsibility—one that I feel toward my mentees and those aspiring to pursue medicine. Paying it forward is a responsibility that all physicians should assume, but it becomes deeper when I think about my experience as both a minority and a woman.

The United States has become significantly more diverse over the last several decades. To meet the needs of the population, the people providing medical care need to reflect this cultural diversity.

In this essay, current medical students discussed the consequences of patients’ inability to find culturally humble care such as avoidance or delay of care, recruitment of a diverse set of medical students, and the role mentorship can play in retaining students so they can thrive as future physicians. Exceptional physician care encompasses considering cultural avenues of providing treatments, ensuring that a translation service is used if needed, and never making patients feel less than or othered. Medical mistrust is a common theme among minority populations. Physicians must work to earn their patients’ trust in hopes of providing better outcomes for patients and their families while paving the way for incoming URiM medical students and supplying a place for them to grow academically and personally.

While the personal accounts in this essay were not an exhaustive portrait of underrepresented medical students, the authors seek to encourage more accounts from students and to inspire further recommendations. While every student has their own unique experience in academia and medicine, important considerations must include the interplay between recruitment, retention, and the realization of lived experiences. An overarching theme in the narratives is cultural humility. Additional key themes from the medical students’ reflections include endorsement of the importance of mentorship and accessibility to resources for URiM students. Mentors pave a path of success for incoming students, foster a sense of achievement, and make increasing retention rates of underrepresented students a plausible feat.

Future directions include highlighting successful pathway programs; reenvisioning what diversity, equity, and inclusion looks like in a climate with an anti-DEI legislature and rhetoric; and encouraging continued community engagement in underserved communities. Programs worth investment include those targeting underrepresented youth and medical students. Youth programs improve access to tools that will make students successful in pursuing a career in medicine. ^{16, 17} Further recommendations include investing in meaningful, evidence-based mentorship relationships that provide official mentor-mentee partnerships, ¹⁸ providing educational programs designed specifically for improved retention, ¹⁹ and recruiting students to residency programs with URiM faculty and core tenants of cultural humility. ²⁰ Purposeful recruitment of URiM students at institutions that create environments where they will be socially supported is a critical step. Recommendations from the Associated Medical Schools of New York suggest that interventions such as mentorship and peer groups indicate higher retention for STEM (science, technology, engineering, and mathematics) fields. ²¹ Acknowledging this need is the first step toward providing better care for all patients, with higher representation rates for marginalized communities. However, these necessary interventions reach past medical education and must extend beyond the entire educational system. The value of a diverse workforce is not unique to medicine; it is essential across all sectors. The responsibility to create workforces in all sectors—engineering, education, arts, politics, etc—that reflect the population of the United States lies with each one of us. This meaningful work cannot reside solely on the shoulders of underrepresented physicians, students, educators, and leaders. Creating a more equitable workforce should be a collective responsibility involving everyone’s active participation.