
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39192722
10.7812/TPP/24.085
TPJ-24-085
Original Research
Evaluating the Impact of Gender, Race, and Training Year on Internal Medicine Residents’ Experiences Across the United States
http://orcid.org/0009-0008-3564-4435
Kim Grace BS 1
Lodha Shweta BA 1
Wein Lulu BA 1
Fahs Lily BA 1
Allen Ariana MD 1
Rathinavelu Jay MD 1
Sharma Poonam MD 2
http://orcid.org/0000-0003-4403-5996
Fekrat Sharon MD, FACS 3
1 Duke University School of Medicine, Durham, North Carolina, USA
2 Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
3 Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, USA
Sharon Fekrat, MD, FACS fekra001@mc.duke.edu
GK and SL contributed equally.

Supplementary Materials: Supplemental Material is available at: www.thepermanentejournal.org/files/2024/24.085supp.pdf

2024
28 8 2024
28 3 107116
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Introduction

Prior studies have highlighted experiences of bias within resident training based on trainees’ gender and race and high rates of burnout. However, few studies have addressed the intersection between bias and wellness for residents in internal medicine (IM) programs. This study explores how race, gender, and training year affect IM residents’ bias experiences and well-being.

Methods

An anonymous survey with questions evaluating demographics and resident experiences of bias and perceptions of wellness and self-efficacy was distributed to 596 IM programs across the United States. Sixty-nine programs sent out the survey to their IM residents. Respondents to the survey included 176 residents. Descriptive analyses and χ2 tests were performed.

Results

Responses demonstrated that gender and race impacted residents’ experiences with bias and misidentification. Eighty-eight percent of women compared to 1% of men, and 89% of Black residents compared to 3% of White residents reported being misidentified as a nonphysician due to gender and race, respectively. Degrees to which residents felt they were thriving in residency, experiencing burnout, and utilizing their strengths varied significantly by gender. Residents’ self-perceived burnout levels were associated with being misidentified as not being a physician due to race. Experiences with bias also increased significantly with training year.

Discussion

This study provides important insights into the impact of gender, race/ethnicity, and training year on IM residents’ experiences with bias and self-perception.

Conclusion

The findings emphasize the need for structural changes within IM residency programs to reduce experiences of bias and to better cultivate the wellness of residents.

Keywords:

bias
wellbeing
residency
Internal Medicine
sociodemographic
==== Body
pmcIntroduction

Gender and racial biases are prevalent in all industries, including health care and medical education. Many studies have revealed evidence of bias in medical student and resident training, faculty evaluation, and patient care.1–10 Faculty assessments of residents have been found to vary based on trainees’ gender and race, with female residents receiving poorer evaluations in performance domains1,3,7,11 and racial and ethnic minority residents receiving lower assessment scores.6,12 Female residents and faculty physicians have been found to experience microaggressions and be misidentified as the traditionally female nurse more often than their male counterparts.2,5 Similarly, interviews with Black, Hispanic, and American Indian physician residents from diverse specialties have revealed that residents from underrepresented racial and ethnic groups experience a significantly greater burden of bias, tokenization, and microaggressions than do White trainees.13

Studies have also found that medical trainees are at high chance of experiencing burnout and reduced wellness.14 Although burnout rates vary among specialties and studies, a 2021 systematic review estimated the prevalence of burnout among residents throughout the world to be 47.3%.15 Residents may concurrently struggle to seek help because of perceived negative consequences to their career.16 High burnout rates not only negatively impact trainees’ overall educational experiences17 but also result in unfavorable patient outcomes.18,19

The interplay between resident wellness and bias is complex. Analysis of the American Medical Colleges Graduation Questionnaire found that medical trainees who identified as underrepresented reported higher levels of exhaustion related to burnout and less favorable trainee-faculty interactions.20 Gendered and racial microaggressions have been associated with burnout2,21–23 and negative self-perceptions.24 Additionally, increased resident burnout has been associated with increased explicit and implicit racial biases.25

Prior publications demonstrated the existence of discrimination and burnout within residency, but only a few have examined the intersection of bias and wellness within internal medicine (IM) programs specifically. In this study, the authors sought to explore the perceived impact of race, gender, and training year on IM residents’ experiences with bias and their well-being across the United States.

Methods

The anonymous survey consisted of 59 questions on demographics and resident experiences, including those pertaining to bias and wellness (Table 1). Survey questions were developed by a group of faculty members, residents, and medical students through an iterative process that included reviewing existing literature for content gaps, devising a comprehensive list of questions, and developing an online survey. The finalized survey was distributed via social media and email to 596 Accreditation Council for Graduate Medical Education (ACGME)-accredited IM program coordinators across the United States. Survey respondents were required to log in via Gmail to verify each person could respond only once. In the survey, a clear statement was made to respondents that no identifying information would be collected. The Duke University Institutional Review Board reviewed this study and determined it to be exempt.

Table 1: Survey questions assessing bias experiences and self-perception/wellness

Question Letter	Question Text	
Experience With Bias Survey Questions	
 A	Have you experienced some form of bias from faculty you have worked with?	
 B	Have you witnessed some form of bias toward other residents from faculty you have worked with?	
 C	Do you feel excluded by your mentors/faculty/attendings because of your race?	
 D	Do you feel excluded by your mentors/faculty/attendings because of your gender?	
 E	If a team has multiple learners (residents, medical students, PA students), do you feel that they are likely to give equal attention to all trainees regardless of race?	
 F	If a team has multiple learners (residents, medical students, PA students), do you feel that they are likely to give equal attention to all trainees regardless of gender?	
 G	Has someone assumed you were not a doctor due to your race?	
 H	Has someone assumed you were not a doctor due to your gender?	
 I	Do you feel that bias due to race has an impact on receiving research opportunities/training from faculty?	
 J	Do you feel that bias due to gender has an impact on receiving research opportunities/training from faculty?	
 K	How do you feel your relationship is with other residents in your specialty?	
 L	How do you feel the faculty in the department of your specialty treats residents?	
Self-Perception and Wellness Survey Questions	
 M	I feel I am thriving in residency.	
 N	I feel burned out from residency.	
 O	I have a chance to utilize my strengths every day as part of my training.	
 P	Do you feel confident in your ability to take care of patients independently?	
PA, physician assistant.

Sixty-nine programs responded that they had sent out the survey to their respective programs, 11 declined, specifying that they could only send internal and/or institution-verified surveys, and 516 programs did not respond to the original email and 2 follow-up emails. Descriptive analyses were performed, followed by χ2 tests to identify significant associations in responses within genders, race/ethnicities, and training year as well as significant associations between questions concerning bias and well-being. Fisher’s exact tests were used if more than 20% of cells had expected counts less than 5. All analyses and analytical assumptions were performed using SAS v9.4 (SAS Institute, Cary, NC).

Results

A total of 176 IM residents responded to the survey. The demographic characteristics of the survey respondents, as compared to the 2022–2023 ACGME gender and race/ethnicity distribution of IM residents nationwide, are shown in Table 2.

Table 2: Survey respondents' demographics and ACGME’s 2022-2023 Data Resource Book with internal medicine residents' self-identified gender and race/ethnicity

Demographics	
	Survey	ACGME	
Gender	
Woman	89 (50.6%)	38.7%	
Man	86 (48.9%)	61.3%	
Nonbinary	1 (0.5%)	N/A	
Race	
Asian, Pacific Islander	48 (27.3%)	36.7%	
Black	9 (5.1%)	6.5%	
White	79 (44.9%)	35.2%	
Middle Eastern/North African	15 (8.5%)	N/A	
Hispanic/Latinx	12 (6.8%)	9.6%	
Multiracial a	8 (4.5%)	4.0%	
Unknown	2 (2.8%)	3.6%	
Training Year	
PGY1	52 (29.5%)	N/A	
PGY2	58 (33.0%)	N/A	
PGY3	61 (34.7%)	N/A	
PGY4+	5 (2.8%)	N/A	
Location	
Midwest	48 (27.3%)	N/A	
Northeast	48 (27.3%)	N/A	
South	57 (32.4%)	N/A	
West	23 (13.1%)	N/A	
a Multiracial individuals consisted of 2 Asian, Pacific Islander-Caucasian, 1 Black-Indigenous/American Indian-Caucasian, 1 Black-Middle Eastern/North African, 1 Hispanic/Latinx-Caucasian, 3 Middle Eastern/North African-Caucasian self-reported identities.

ACGME, Accreditation Council for Graduate Medical Education; N/A, not available; PGY, postgraduate year.

Impact of Race, Gender, and Training Year on Experiences with Faculty and Trainees

A significant association was observed between gender and residents’ reported experiences with faculty demonstrating bias toward other trainees, residents’ perception of being excluded by faculty based on gender, residents' belief that bias due to gender impacts their ability to receive opportunities from faculty, and residents’ ranking of how faculty treat trainees (Table 3, questions B–M). More women than men reported witnessing faculty demonstrate bias toward other trainees and feeling excluded by mentors due to gender (Table 3, questions B and D). Moreover, a greater percentage of women agreed that bias due to gender influences research and training opportunities that residents are afforded by faculty (Table 3, question K). Gender did not influence residents' perception of their relationship with fellow trainees (Table 3, question L) or their belief that race impacts the interactions they and other trainees had with faculty (Table 3, questions C, E, and J).

Table 3: Response percentages and chi-square or Fisher’s exact test p values for questions assessing experiences with bias (A-L) and wellness/self-perception (M-P) by gender

Associations between gender and experiences with bias and self-perception/wellness	
Q	Women	Men	P Value	
	Yes	No	NS	Yes	No	NS	 	
A	30 (33.7)	59 (66.3)	N/A	21 (24.4)	65 (75.6)	N/A	.16	
B	38 (42.7)	51 (57.3)	N/A	23 (26.7)	63 (73.3)	N/A	.02 a	
C	4 (4.5)	78 (87.6)	7 (7.9)	7 (8.1)	78 (90.7)	1 (1.2)	.07	
D	10 (11.2)	70 (78.7)	9 (10.1)	2 (2.3)	84 (97.7)	0	< .001 a	
E	68 (76.4)	21 (23.6)	N/A	71 (82.6)	15 (17.4)	N/A	.29	
F	60 (67.4)	29 (32.6)	N/A	71 (82.6)	15 (17.4)	N/A	.02 a	
G	21 (23.6)	53 (59.5)	15 (16.8)	7 (8.1)	70 (81.4)	9 (10.5)	.007 a	
H	78 (87.6)	8 (9.0)	3 (3.4)	1 (1.2)	76 (88.4)	9 (10.5)	< .001 a	
I	30 (33.7)	59 (66.3)	N/A	25 (29.1)	61 (70.9)	N/A	.48	
J	34 (38.2)	55 (61.8)	N/A	21 (24.4)	65 (75.6)	N/A	.04 a	
	Low	Neutral	High	Low	Neutral	High	 	
K	3 (3.4)	14 (15.7)	72 (80.9)	2 (2.3)	8 (9.3)	76 (88.4)	.37 a	
L	4 (4.5)	14 (15.7)	71 (79.8)	0	6 (7.0)	80 (93.0)	.02 a	
M	14 (15.7)	26 (29.2)	49 (55.1)	5 (5.8)	21 (24.4)	60 (69.8)	.04 a	
N	14 (15.7)	30 (33.7)	45 (50.6)	27 (31.4)	31 (36.0)	28 (32.6)	.01 a	
O	12 (13.5)	28 (31.5)	49 (55.1)	8 (9.3)	12 (14.0)	66 (76.7)	.007 a	
P	31 (34.8)	58 (65.2)	0	20 (23.3)	66 (76.7)	0	.08	
Notes: Yes, No, and NS were the response options for questions A–J. Low, Neutral, and High were the response options for questions K–P.

a p value < .05 was statistically significant.

N/A, not available; NS, not sure; Q, question.

Race/ethnicity was significantly associated with residents’ personal experiences with faculty bias and being excluded by faculty due to their race and their belief that race impacts research opportunities (Table 4, questions A, J, and K). More Black residents reported experiencing biased and exclusionary treatment from faculty compared to respondents from all other racial/ethnic groups (Table 4, questions A and C). Compared to 22.2% of Black residents, 0% of White residents responded “not sure” when asked whether they experienced exclusion by faculty (Table 4, question C). A greater percentage of Black residents held the belief that learners’ experiences can be affected by race and that racial bias can impact research opportunities, compared to their counterparts from other racial/ethnic groups (Table 4, questions E and I). No significant association was seen between race/ethnicity and residents’ observation of faculty exhibiting bias toward other trainees and residents’ perceptions of their relationships with both faculty and fellow residents (Table 4, questions B, K, and L).

Table 4: Response percentages and chi-square or Fisher’s exact test p values for questions assessing experiences with bias (A-L) and wellness/self-perception (M-P) by race/ethnicity

Associations between race/ethnicity and bias experiences and self-perception/wellness	
Q	Asian, Pacific Islander (n, %)	Black (n, %)	White (n, %)	Middle Eastern/North African (n, %)	Hispanic/Latinx (n, %)	Multiracial (n, %)	Unknown (n, %)	P Value	
	Yes	No	NS	Yes	No	NS	Yes	 No	NS	Yes	No	NS	Yes	No	NS	Yes	No	NS	Yes	No	NS		
A	18 (37.5)	30
(62.5)	0	7
(77.8)	2
(22.2)	0	17 (21.5)	62 (78.5)	0	5 (33.3)	10 (66.7)	0	1 (8.3)	11 (91.7)	0	2 (25.0)	6 (75.0)	0	2 (40.0)	3 (60.0)	0	<0.003*	
B	18 (37.5)	30
(62.5)	0	7
(77.8)	2
(22.2)	0	25 (31.6)	54 (68.4)	0	4 (26.7)	11 (73.3)	0	3 (25.0)	9 (75.0)	0	4 (50.0)	4 (50.0)	0	1 (20.0)	4 (80.0)	0	0.06	
C	6
(12.5)	39
(81.2)	3
(6.2)	2
(22.2)	5
(55.6)	2
(22.2)	1
(1.3)	78 (98.7)	0	1
(6.7)	13 (86.7)	1
(6.7)	0	10 (83.3)	2 (16.7)	0	8 (100.0)	0	1 (20.0)	4 (80.0)	0	<0.001*	
D	5
(10.4)	40
(83.3)	3
(6.2)	2
(22.2)	5
(55.6)	2
(22.2)	3 (3.8)	74 (93.7)	2 (2.5)	2 (13.3)	12 (80.0)	1
(6.7)	0	11 (91.7)	1 (8.3)	0	8 (100.0)	0	0	5 (100.0)	0	0.08	
E	35 (72.9)	13
(27.1)	0	2
(22.2)	7
(77.8)	0	72 (91.1)	7 (8.9)	0	11 (73.3)	4
(26.7)	0	10 (83.3)	2 (16.7)	0	6 (75.0)	2 (25.0)	0	4 (80.0)	1 (20.0)	0	<0.001*	
F	32 (66.7)	16
(33.3)	0	2
(22.2)	7
(77.8)	0	68 (86.1)	11 (13.9)	0	11 (73.3)	4
(26.7)	0	11 (91.7)	1 (8.3)	0	4 (50.0)	4 (50.0)	0	4 (80.0)	1 (20.0)	0	<0.001*	
G	9 (18.7)	29
(60.4)	10
(20.8)	8
(88.9)	0	1
(11.1)	2
(2.5)	70 (88.6)	7 (8.9)	4 (26.7)	9
(60.0)	2 (13.3)	2 (16.7)	7 (58.3)	3 (25.0)	2 (25.0)	5 (62.5)	1 (12.5)	1 (20.0)	4 (80.0)	0	<0.001*	
H	19 (39.6)	25
(52.1)	4
(8.3)	8
(88.9)	0	1
(11.1)	38 (48.1)	35 (44.3)	6 (7.6)	4 (26.7)	11 (73.3)	0	6 (50.0)	6 (50.0)	0	3 (37.5)	5 (62.5)	0	1 (20.0)	3 (60.0)	1 (20.0)	0.11	
I	17 (35.4)	31
(64.6)	0	7
(77.8)	2
(22.2)	0	23 (29.1)	56 (70.9)	0	4 (26.7)	11 (73.3)	0	3 (25.0)	9 (75.0)	0	1 (12.5)	7 (87.5)	0	0	5 (100.0)	0	0.02*	
J	17 (35.4)	31
(64.6)	0	7
(77.8)	2
(22.2)	0	24 (30.4)	55 (69.6)	0	2 (13.3)	13 (86.7)	0	3 (25.0)	9 (75.0)	0	3 (37.5)	5 (62.5)	0	0	5 (100.0)	0	0.01*	
	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High		
K	1
(2.1)	6
(12.5)	41
(85.4)	0	3
(33.3)	6 (66.7)	1
(1.3)	9
(11.4)	69 (87.3)	1
(6.7)	2
(13.3)	12 (80.0)	0	1 (8.3)	11 (91.7)	0	1 (12.5)	7 (87.5)	2 (40.0)	0	3 (60.0)	0.10	
L	2
(4.2)	5
(10.4)	41
(85.4)	1
(11.1)	1
(11.1)	7 (77.8)	1
(1.3)	11 (13.9)	67 (84.8)	0	2
(13.3)	13 (86.7)	0	0	12 (100.0)	0	1 (12.5)	7 (87.5)	0	0	5 (100.0)	0.74	
M	4
(8.3)	13
(27.1)	31
(64.6)	0	3
(33.3)	6 (66.7)	11 (13.9)	23 (29.1)	45 (57.0)	1
(6.7)	3
(20.0)	11 (73.3)	1 (8.3)	3 (25.0)	8 (66.7)	1 (12.5)	1 (12.5)	6 (75.0)	1 (20.0)	1 (20.0)	3 (60.0)	0.98	
N	17 (35.4)	15
(31.2)	16
(33.3)	1
(11.1)	4
(44.4)	4 (44.4)	17 (21.5)	28 (35.4)	34 (43.0)	1
(6.7)	9
(60.0)	5 (33.3)	4 (33.3)	2 (16.7)	6 (50.0)	0	2 (25.0)	6 (75.0)	1 (20.0)	1 (20.0)	3 (60.0)	0.10	
O	4
(8.3)	13
(27.1)	31
(64.6)	2
(22.2)	1
(11.1)	6 (66.7)	9 (11.4)	22 (27.8)	48 (60.8)	2 (13.3)	0	13 (86.7)	2 (16.7)	1 (8.3)	9 (75.0)	1 (12.5)	3 (37.5)	4 (50.0)	0	1 (20.0)	4 (80.0)	0.36	
P	13 (27.1)	N/A	35
(72.9)	2
(22.2)	N/A	7
(77.8)	24 (30.4)	N/A	55 (69.6)	3 (20.0)	N/A	12 (80.0)	5 (41.7)	N/A	7 (58.3)	2 (25.0)	N/A	6 (75.0)	2 (40.0)	3 (60.0)	N/A	0.92	
Notes: Yes, No, and NS were the response options for questions A–J. Low, Neutral, and High were the response options for questions K–P.

a p value < .05 was statistically significant.

N/A, not available; NS, not sure; Q, question.

A significant association was observed between training year and residents’ experiences with bias and exclusion (Table 5, questions B–F). The number of residents who reported experiences with faculty bias and exclusion due to race increased with training year (Table 5, questions B and C). Furthermore, the proportion of residents who believed that race impacts the way faculty members treat multiple learners on a given team increased with training year (Table 5, question E). As training year increased, the percentage of residents who endorsed the belief that faculty treat team members equally regardless of their race decreased (Table 5, question F). Training year did not impact residents’ belief about whether research and training opportunities vary as a function of race or gender (Table 5, questions J and L).

Table 5: Response percentages and chi-square or Fisher’s exact test p values for questions assessing experiences with bias (A-L) and wellness/self-perception (M-P) by year of training

Associations between year of training and bias experiences and self-perception/wellness	
Q	PGY1 (n, %)	PGY2 (n, %)	PGY3 (n, %)	PGY4+ (n, %)	P Value	
	Yes	No	NS	Yes	No	NS	Yes	No	NS	Yes	No	NS	 	
A	10 (19.2)	42 (80.8)	N/A	20 (34.5)	38 (65.5)	N/A	20 (32.8)	41 (67.2)	N/A	2 (40.0)	3
(60.0)	N/A	.24	
B	11 (21.2)	41 (78.8)	N/A	22 (37.9)	36 (62.1)	N/A	25 (41.0)	36 (59.0)	N/A	4 (80.0)	1
(20.0)	N/A	.02 a	
C	0	52 (100.0)	0	3 (5.2)	53 (91.4)	2
(3.4)	6
(9.8)	49 (80.3)	6
(9.8)	2 (40.0)	3
(60.0)	0	.002 a	
D	2
(3.8)	49 (94.2)	1
(1.9)	2 (3.4)	52 (89.7)	4
(6.9)	7 (11.5)	50 (82.0)	4
(6.6)	1 (20.0)	4
(80.0)	0	.26	
E	48 (92.3)	4
(7.7)	N/A	44 (75.9)	14 (24.1)	N/A	45 (73.8)	16 (26.2)	N/A	3 (60.0)	2
(40.0)	N/A	.02 a	
F	46 (88.5)	6
(11.5)	N/A	39 (67.2)	19 (32.8)	N/A	44 (72.1)	17 (27.9)	N/A	3 (60.0)	2
(40.0)	N/A	.02 a	
G	5
(9.6)	40 (76.9)	7
(13.5)	13 (22.4)	34 (58.6)	11 (19.0)	10 (16.4)	46 (75.4)	5
(8.2)	0 (0)	4
(80.0)	1 (20.0)	.23 a	
H	18 (34.6)	29 (55.8)	5
(9.6)	28 (48.3)	26 (44.8)	4
(6.9)	31 (50.8)	28 (45.9)	2
(3.3)	2 (40.0)	2
(40.0)	1 (20.0)	.36 a	
I	10 (19.2)	42 (80.8)	N/A	22 (37.9)	36 (62.1)	N/A	20 (32.8)	41 (67.2)	N/A	3 (60.0)	2
(40.0)	N/A	.05	
J	11 (21.2)	41 (78.9)	N/A	20 (34.5)	38 (65.5)	N/A	22 (36.1)	39 (63.9)	N/A	3 (60.0)	2
(40.0)	N/A	.14	
	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	Low	Neutral	High	 	
K	1
(1.9)	10 (19.2)	41 (78.9)	3
(5.2)	5
(8.6)	50 (86.2)	1
(1.6)	6
(9.8)	54 (88.5)	0	1
(20.0)	4 (80.0)	.45	
L	1
(1.9)	4
(7.7)	47 (90.4)	0	7
(12.1)	51 (87.9)	3
(4.9)	8
(13.1)	50 (82.0)	0	1
(20.0)	4 (80.0)	.49	
M	5
(9.6)	19 (36.5)	(53.8)	7 (12.1)	15.9 (25.9)	36 (62.1)	7 (11.5)	12 (19.7)	42 (68.8)	0	1
(20.0)	4 (80.0)	.58	
N	18 (34.6)	21 (40.4)	13 (25.0)	14 (24.1)	20 (34.5)	24 (41.4)	7 (11.5)	19 (31.1)	35 (57.4)	2 (40.0)	1
(20.0)	2 (40.0)	.01 a	
O	6
(11.5)	13 (25.0)	33 (63.5)	7 (21.1)	16 (27.6)	35 (60.3)	7 (11.5)	11 (18.0)	43 (70.5)	0	1
(20.0)	4 (80.0)	.93	
P	26
(50.0)	N/A	26 (50.0)	40
(69.0)	N/A	18 (31.0)	54 (88.5)	N/A	7 (11.5)	5 (100.0)	N/A	0	< .001 a	
Notes: Yes, No, and NS were the response options for questions A–J. Low, Neutral, and High were the response options for questions K–P.

a p value < .05 was statistically significant.

N/A, not available; NS, not sure; PGY, postgraduate year; Q, question.

Impact of Race, Gender, and Training Year on Resident Experiences with Misidentification

A significant association was seen between gender and residents’ experiences with being misidentified in a role other than a physician due to their gender and race. Eighty-eight percent of women compared to 1% of men endorsed that it was assumed that they were not a doctor due to their gender; 24% of women compared to 8% of men reported experiences of others assuming that they were not a doctor due to their race (Table 3, questions G and H). Race/ethnicity was also significantly associated with residents’ experiences with being misidentified, with 89% of Black residents compared to 3% of White residents experiencing others assuming that they were not a doctor due to race (Table 4, question G). No association was seen between training year and residents’ experiences with assumptions about not being a doctor due their race or gender (Table 5, questions G and H).

Impact of Race, Gender, and Training Year on Resident Self-Perception and Wellness

Gender significantly influenced resident self-perceptions, as defined by residents’ rating of the degree to which they felt that they were thriving during residency, were experiencing burnout, or had a chance to utilize their strengths daily (Table 3, questions M–O). More men than women provided the highest level of agreement with statements declaring that they were thriving during residency and had a chance to use their strengths daily (Table 3, questions M and O). Contrastingly, more women than men strongly indicated they were burned out (Table 3, question N). Gender did not influence residents’ reported confidence over their ability to care for patients independently (Table 3, question P). There were no significant associations between race/ethnicity and resident self-perception (Table 4, questions K–P). A significant association was seen between training year and resident burnout, with the proportion of residents who maximally endorsed burnout increasing with training year (Table 5, question N).

Associations Between Resident Experiences With Bias and Self-Perception/Wellness

A significant association was seen between residents’ assessments of their level of burnout and whether others assumed that they were not a doctor due to race. Responses to a question assessing whether residents had ever been assumed by others to not be a doctor due to gender were significantly associated with residents’ ratings of how much they felt they were thriving during residency, how burned out they felt, and how much they believed that they utilize their strengths daily (Table S1).

Discussion

In this study, the authors conducted a nationwide survey of IM residents, querying their experiences with wellness and bias during training. The authors’ findings suggest that gender, race/ethnicity, and training year impact residents’ self-perception and experiences with bias and ultimately suggest considering structural reformations within IM residency programs that prioritize equity and minimize implicit bias and resultant discrimination. The authors’ findings support prior research highlighting the effects of gender and race on residents' access to leadership opportunities and social support systems and their experiences with evaluation and patient microaggressions.1,2,5,7,13,26 However, existing studies have largely focused on the experience of residents in surgical specialties23,27–30 and have been limited to single-institution surveys.5,6,13,31 By surveying IM residents nationwide, this study attempts to address such gaps in the literature. This study furthers the understanding of how race and gender can influence IM residents’ well-being and experiences with bias and provides potential avenues to mitigate disparities existing within academic medicine and clinical practice.5,32

Gender/Race/Training Year’s Impact on Resident Experiences with Bias

In this study, significantly more women stated that they had experienced exclusionary treatment due to their gender, aligning with prior findings.5,33 In a recent publication by Chatterjee et al exploring gender bias experiences by IM residents in one institution, 98% of females, compared to 19% of males, reported experiences with gender bias. Moreover, 90% of males compared to 98% of females stated that they had observed residents experiencing gender bias.5 Although these findings suggest an awareness among male residents of how gender bias may appear, in this study, only 27% of men endorsed experiences with observing faculty demonstrate gender bias toward other residents. The difference in the percentage of men and women who reported experiences with observing faculty demonstrating gender bias may in part be due to women having a greater awareness of, and thus being more likely to notice, how gender can influence treatment. The discrepancy between this study and the Chatterjee study highlights the need for further cross-institutional investigation of trainees’ interpretation and perception of gender bias manifestations. Of note, in this study, 24% of men residents endorsed experiences with gender bias, suggesting that men may also be stereotyped and demonstrating a need to clarify their experiences during residency.

This study also suggests that race/ethnicity may impact IM residents’ experiences with bias. The authors’ findings are in line with prior literature indicating that Black residents are more likely to experience faculty bias and be misidentified as being in a nonphysician role.12,13,31,32 In this study, residents of all racial/ethnic groups other than those who identified as White residents expressed uncertainty about whether they had experienced bias from faculty. This finding highlights the existence of racial privileges disproportionately benefiting White trainees and a coexisting lack of confidence among certain racial/ethnic groups over what constitutes discrimination. However, the percentage of White residents who indicated that race impacts receipt of research opportunities was comparable to that of Asian/Pacific and Hispanic/Latinx residents, suggesting an awareness of the challenges faced by underrepresented groups in accessing opportunities. Based on this finding, it may be most beneficial for curricular interventions aimed at reducing racial discrimination to go beyond educating residents on what racial bias might look like and provide information and resources to facilitate residents intervening during such instances. It may be difficult for residents to intervene when they observe discrimination because of fear of professional retaliation.16 To address such barriers, it may be beneficial for program directors and faculty to develop and refine a training culture that does not penalize honest communication.

This study revealed that trainees’ observations of faculty demonstrating biased behavior toward other residents increased with training year. This may be attributed to more residents developing greater awareness of how bias can present itself as they progress in their training. In contrast, a study evaluating implicit gender bias among emergency medicine (EM) and OB/GYN residents found no significant relationship between implicit associated test scores and residency year.26 These findings indicate that although awareness of explicit biases may increase throughout training, implicit biases persist, highlighting the need for programs to provide residents and faculty members with training to recognize and mitigate both explicit and implicit biases in pursuit of creating a more equitable culture.

Gender/Race/Training Year’s Impact on Resident Self-Perceptions

In this study, fewer women than men residents expressed that they were thriving during training and utilizing their strengths daily. This aligns with prior literature suggesting that female residents are more likely to perceive gender as inhibiting their clinical abilities.34 Gender-based discrepancies in self-perception likely arise from multifaceted reasons, including differential exposure to microaggressions and/or differences in the way male and female residents are evaluated by faculty.7,33 A qualitative study examining gender differences in faculty feedback to EM residents showed that male residents were more likely to receive consistent feedback about their technical abilities while female residents more often received inconsistent feedback focused on their demonstration of assertiveness and autonomy.7 Although a prior study investigating the influence of gender on faculty evaluations of residents within IM reported no significant impact, this study limited its focus to 2 residency programs and was limited in its ability to assess performance evaluations accurately.35 Further investigation is needed to understand whether gender bias affects resident evaluations within IM and the impact faculty assessments may have on residents’ overall self-perception and confidence.

Despite significant associations seen between race/ethnicity and resident experiences with bias, residents’ reported well-being and self-perception of their success during training did not vary significantly by race. These findings suggest an element of resilience among those who acknowledged experiences with racial bias, such that residents who experienced racial/ethnic discrimination were able to preserve their sense of efficacy and self-worth.36 However, this study demonstrated that being misidentified as being in a nonphysician role due to race was associated with feelings of burnout, suggesting that the invalidation and questioning of one’s legitimacy and competence can lead to increased stress and emotional exhaustion. In contrast to the authors’ findings, a study by Greenberg et al found that general surgery residents of color had significantly lower well-being and higher anxiety compared to their White counterparts.37 Another study by Sotto-Santiago et al showed that Black IM residents were 9.5 times more likely than White residents to feel a need to minimize aspects of their race to fit into their program’s culture, 25 times more likely than White residents to feel isolated, and 7 times more likely than White residents to feel the need to work harder to get the same treatment.32 A possible explanation for the differences between this study and the Greenberg study is that the latter broadly focused on the experiences of residents in multiple specialties with an emphasis on general surgery residents. Additionally, the differences between this study and the Sotto-Santiago study highlight the need to further elucidate the complex interplay among racial identity, institutional culture, and resident well-being and self-perception within training environments.

Reported burnout increased with training year, which can be explained by residents being given more responsibility, including increased administrative tasks.38 In contrast, a study examining burnout levels across 8 specialties found that the first year of residency was independently associated with burnout.39 Another study found a decrease in emotional exhaustion in IM residents from their first to third year of training.40 These studies, however, were single-institution surveys, and program-specific factors thus may have helped mitigate burnout with increased training. Although residents’ sense of burnout increased with training year, their confidence in their ability to care for patients independently also increased, reflecting the positive impact increased clinical experience can have in fostering residents’ sense of proficiency.

Limitations

The study has several limitations. Despite the survey being distributed to 596 residency programs, only 12% of programs responded that they would disseminate the survey to their residents. The low response rate may be due to survey fatigue, whereby respondents may receive a large number of qualitative assessments during training and subsequently have felt overwhelmed and lacked motivation to fill out this survey.41 Many prior studies surveying IM residents to understand their training experiences had a smaller sample size than in this study,17,26,28 exemplifying the challenge in collecting comprehensive, nationwide data on trainee experiences. Barriers in obtaining representative data limit the authors’ ability to advance discussions about resident wellness and bias. They also present a need for more effective methods to evaluate the experiences of residents during training that incentivize survey completion or utilize a different tool for assessing experiences.

Additionally, due to the small sample size of the nonbinary population in this study (n = 1), the authors were unable to meaningfully evaluate the experiences based on gender for this population and excluded this group in the gender analysis. The authors also grouped together certain sociodemographic groups, such as individuals with multiple self-reported racial identities as “multiracial,” to increase the statistical power. This highlights the underrepresentation of certain identities within IM residency programs and underscores the need to perform a more detailed assessment of their experiences. Additionally, χ2 analyses examined associations without considering the intersectionality of sociodemographic variables. Further research examining this intersectionality and its impact on resident experiences may facilitate the development of targeted interventions.

Conclusion

This study highlights the impact of sociodemographic variables on IM residents’ experiences with bias and wellness. Addressing these issues will promote a more diverse, equitable, and supportive learning environment within IM residency programs, ultimately improving patient care.

Supplementary Material

online supplementary file 1

Acknowledgments

Grace Kim, BS, and Shweta Lodha, BA, are co-first authors and contributed equally.

Author Contributions: Grace Kim, BS, and Shweta Lodha, BA, participated in the study design, acquisition and analysis of data, drafting and critical review of the final manuscript, and submission of the final manuscript. Lulu Wein, BA, and Lily Fahs, BA, participated in the study design, acquisition of data, and drafting of the final manuscript. Ariana Allen, MD, and Jay Rathinavelu, MD, participated in the study design and acquisition of data. Poonam Sharma, MD, participated in the drafting of and critical review of the final manuscript. Sharon Fekrat, MD, FACS, participated in the study design, acquisition of data, and drafting of and critical review of the final manuscript. All authors have given final approval to the manuscript.

Conflict of Interest: The authors have no competing interests. Dr Fekrat is supported by Optos, Genetech, Glaukos, Alimera, Apellis, Bausch Surgical, and Retina Society Website Committee and has an Alcon patent. Dr Sharma is supported by Aquifer and the American College of Physicians. An abstract was accepted to the 2024 Society of General Internal Medicine Annual Meeting on May 18, 2024.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data-Sharing Statement: Data are available upon reasonable request. Readers may contact the corresponding author to request underlying data.
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