Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program

Key Points Question What are the experiences of trainees with respect to discrimination, bias, and inclusion during hematology and oncology fellowship? Findings In this qualitative study of anonymous hotline interviews with 17 fellows, 100% of the fellows reported experiencing or witnessing discriminatory behavior, mostly from patients; a novel theme was alien at home, referring to US citizens from racial or ethnic minority groups treated as other or foreign. Reporting was infrequent due to belief of futility; and diversity of the fellows in the program contributed a sense of inclusion. Meaning These findings suggest that hematology and oncology trainees need better protection from discrimination and processes for reporting witnessing of discrimination.
This qualitative study investigates the experiences of discrimination and inclusion among trainees and recent graduates of a US hematology and oncology fellowship program.
Importance Medical trainees frequently experience discrimination. Understanding their experiences is essential to improving learning environments. Objective To characterize trainee experiences of discrimination and inclusion to inform graduate medical education (GME) policies. Design, Setting, and Participants This qualitative study used an anonymous telephone interview technique to gather data from hematology and oncology fellows. All current trainees and recent graduates were eligible. Interviews were conducted anonymously with interviewer and participant in separate locations and recorded and transcribed. Data were analyzed in an iterative process into major themes using a general inductive analysis approach. Demographic information was obtained via anonymous survey. Data collection and analysis were conducted from July 2018 to November 2019. Main Outcomes and Measures Emergent themes illustrating bias and inclusion in a GME program. Results Among 34 fellows and recent graduates who were approached for this study, 20 consented and 17 were interviewed. Of those interviewed, 10 were men, and the median (range) age was 32 (29-53) years. The racial and ethnic distribution included 6 Asian individuals, 2 Black individuals, 3 Hispanic individuals, 2 multiracial individuals, and 4 White individuals. All fellows reported having experienced and/or witnessed discriminatory behavior. The themes elucidated were (1) foreign fellows perceived as outsiders, (2) US citizens feeling alien at home, (3) gender role-typing, (4) perception of futility of reporting, (5) diversity and inclusion, and (6) coping strategies. The majority of reported biases were from patients. Only 1 trainee reported any incidents. Reasons for not reporting were difficulty characterizing discrimination and doubt action would occur. Participants reported that diversity of cotrainees, involvement in committees, and open discussions promoted inclusivity. Conclusions and Relevance In this study, reports of discriminatory behavior toward trainees were common. The anonymous hotline methodology cultivated a safe environment for candid discussions. These findings suggest that GME programs should assess their learning climate regarding bias and inclusivity anonymously and develop processes to support trainees.