Marginalized identities, mistreatment, discrimination, and burnout among US medical students

1. Among a group of US medical students, those with multiple marginalized identities (based on three sociodemographic factors, namely sex, race or ethnicity, and sexual orientation) experienced more mistreatment and discrimination during their medical school education.

2. Higher levels of mistreatment and discrimination appeared to be associated with greater degrees of burnout.

Evidence Rating Level: 2 (Good)

Study Rundown: Mistreatment is a common experience during medical training and has been associated with burnout, often characterized by cynicism, emotional exhaustion, and a low sense of accomplishment. Prior research has demonstrated that students belonging to historically marginalized groups (i.e., female, non-white, and 2SLGBTQ+) are particularly likely to experience mistreatment and discrimination. As per social stress theory, these prejudices act as significant stressors, negatively impacting physical and mental well-being of those belonging to equity-deserving groups. To date, few studies have explored the relationship between a medical student’s intersectional identity and mistreatment and burnout. This retrospective cohort study aimed to fill this gap by investigating the association between a student having multiple marginalized identities and burnout score. Additionally, this study explored how experiences of mistreatment and discrimination influenced burnout scores among medical students with multiple marginalized identities. Data from a national survey administered to 30 651 graduating medical students in 2016 and 2017 at 140 US medical schools accredited by the Association of American Medical Colleges was assessed. Self-reported sex, race or ethnicity, and sexual orientation groups were considered. The association between unique identity groups and burnout along two dimensions (exhaustion and disengagement) was determined. It was found that as the number of marginalized identities that a student holds increases, their scores for exhaustion also increase. Focusing on one aspect of identity might underestimate the degree of harm students with multiple marginalized identities experience in their learning environment.

Click here to read the study in The BMJ

Relevant Reading: Harassment and Discrimination in Medical Training: A Systematic Review and Meta-Analysis

In-Depth [Cross Sectional Survey and Retrospective Cohort Study]: This study used data from the 2016 and 2017 Medical School Graduation Questionnaire, a national survey administered annually by the Association of American Medical Colleges (AAMC) to graduating medical students across the 140 US medical schools that are accredited by the Liaison Committee on Medical Education. The questionnaire contains questions about sociodemographics (sex, race or ethnicity, and sexual orientation), general medical education and student services as well as reports of mistreatment, discrimination, and burnout during undergraduate medical studies. The simultaneous effect of having multiple marginalized identities was examined using an intersectional analysis with the eight unique identity combinations that were possible from the three sociodemographic variables of focus (sex, race or ethnicity, and sexual orientation). To assess mistreatment and discrimination, seven questionnaire items asking about experiences of general mistreatment and nine asking about discrimination targeting one’s gender, race or ethnicity, and sexual orientation were evaluated. Two summary variables were created to reflect varying frequencies of mistreatment and discrimination. Burnout was assessed by the 16 item Oldenburg Burnout Inventory for Medical Students. Data from 30 651 graduating medical students in 2016 and 2017 was available. About half of the respondents (48.5%) reported their sex as female, 10 181 (39.2%) students identified as non-white, and 1419 (5.5%) reported their sexual orientation as 2SLGBTQ+. Overall, 46.0% of all medical school graduates reported experiencing mistreatment. Students with three marginalized identities (female, non-white, 2SLGBTQ+) had the largest proportion reporting recurrent experiences of multiple types of mistreatment (88/299, P<0.001) and discrimination (92/299, P<0.001). Students with a higher number of marginalized identities also had higher average scores for exhaustion. Female students had lower average disengagement scores irrespective of other identities held, which became larger after adjusting for mistreatment and discrimination. Non-white and 2SLGBTQ+ students had higher average disengagement scores than their white and heterosexual counterparts (0.28, 0.19 to 0.37; and 0.73, 0.52 to 0.94; respectively). This study concluded that in a population of US medical students, those with multiple marginalized identities reported more mistreatment and discrimination during medical school, which appeared to be associated with burnout.

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