Conflicts and Resolutions
It is probably a case of six in one hand, half dozen in the other, whether malignant racism,41 on one hand, or communication failure, on the other is the more crucial obstacle to be overcome by aspiring Black medical students. For if there was no racism, there would probably be adequate communications between the medical school and the Black student or if there was adequate communication between the Black student and the medical school, there would probably be less racism institutionalized.
The process of communications can be divided into three basic elements: (1) the source (2) the message and (3) the destination. Each element is constrained by the boundaries36 of the words and symbols manipulated. The words and symbols, in turn, are constrained by the emotional content and context subjectively interpreted by the cultural bounds of both the source and the destination.
Presently, and in the past, communication between white medical schools and Black medical students has been hindered by distorted interpretation of words and symbols exchanged across the hazy interface of cultural boundaries. The challenge to effective communication has always been for both groups to allay enough anxieties that sufficient trust could be built so that their mutual issues would emerge through dialogue - not individual reactions arising through forced encounters.
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In order to facilitate dialogue in an environment designed to foster mutual trust and respect and define the issues responsible for the ... [academic - emotional problems] of non-white students in American medical schools",37 the SNMA convened a "Dynamics of Communications Conference in April 1973. In attendance were more than 300 Black medical students, deans and administrators of Medical Schools, and representatives of major U.S. health organizations.
At that conference one broad category of conflict emerged under the guise of several topical contexts - the extent of commitment and the delegation of responsibility among the health professions, individual medical schools and Black students.
A brief overview of the consensus drawn from the conference workshops would be:
The lack of real administrative commitment to admit and graduate non-white students is a major cause of minority student academic-emotional problems... the lack of programmatic commitment to retain minority students in the curriculum was a primary reason why the medical school environment was [is] judged alien to non-white students and an obstacle to their success... Prediction that non- white medical students would continue to view their success as something of a gamble for which the students were playing with half a deck, without greater school responsibility towards their education in these institutions - including programmatic commitment to the "coping mechanism" needed to resolve student-school problems... the agreement that non-white students were generally seen to be fulfilling their responsibility towards their schools to a far greater degree than the
schools toward them... the agreement that non-white medical students have towards medical school is the same for all students; white and non-white; that is the devotion of the maximum amount of their energies toward successful graduation... that the medical schools' responsibility towards their medical students is the same towards all students, white and non-white. They are responsible for the academic, financial, and emotional well-being of all the students when they admit, regardless of potential differences in race or academic/cultural backgrounds. Included in this mutual responsibility from the moment the student applied to the moment the institution graduates him, students, schools, and funding agencies are responsible for recognizing, learning to define and making every effort to account for the cultural, academic, social and financial differences which may create conflicts between the non-white student and the white medical school environment and obstruct their mutual goal of creating qualified physicians of all races...38 neither the burden of proof nor the recognition of problems within medical school is the responsibility of the non-white medical student. The administration and faculty must awaken to their responsibilities of assuring that acceptance correlates with graduation.39
The conferees recognized that a prime factor contributing to miscommunication is the difficulty of the task of defining accurately the sources and nature of the problems facing Black students and medical schools. It was admitted that too often complex major problems are "cubby-holed" as "learning problems"; "financial problems", etc. when the actual "problem" draws from several areas. Categorization often blurs the distinction between where the problem is perceived and where it originated. In order to break through the custom of
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categorization, this conference used the tool of the Domain Theory.40
The Domain Theory is a training theory which helps distinguish between where a problem is felt and what its nature and origins might be, by postulating three domains which must be recognized and accounted for in any learning situation involving adult individuals. These domains are:
The Cognitive - the area of knowledge, awareness and understanding;
The Motoric - the area of skills, ability and talent; and
The Affective - the area of attitudes, feelings and behaviors.
A corollary to the Domain Theory is that misapplication of or failure to use this technique leads to inappropriate "solutions or Cross-Purposed Solutions.
Emphasis was placed on the impact of the affective domain. Seldom, if ever, do affective domain problems come to grips with fully because they are the last to be recognized. They make people feel uncomfortable, accusatory and defensive. Frequently, these problems are just dismissed - consciously or not, through malice or through ignorance - as ill-defined, personal, risky, out of the bounds of academia, or just plain insignificant compared to "real" problems like needing more money for scholarships. Most frequently, then, solutions to these problems are the ones which go ignored, or are missought in some other, inappropriate domain.
Subservience and Black self-image
"Hostile" is an evaluation commonly made by white faculty, house staff, and students concerning Black medical students.
In numerous interviews with Black medical students in medical schools in every state of the Union, the common complaint of Black medical students was to the effect: Despite or rather, in addition to, oppressing us with racist policies, racist housing, racist grades, racism in general, the whites that turn around and label our most feeble displays of displeasure as hostility, rebelliousness, trying to get a degree without putting out effort, etc... the whites give us poor evaluations because they say we don't have the right "attitude" about medicine.
While the mutual perception of malicious hostility by the other is hazily grounded in stereotypic ego-defense mechanisms of projective denial as a result of cultural shock, another portion of the problem is solidly grounded in the affective domain arising from the Black student's perception of subservience and his own self-image.
As demonstrated previously, specifically using the University of Utah, as an example, but the observation is universally made nationally,42 graduation from medical school depends on one's "human relations" evaluation, to the greater extent. This evaluation is a reflection of the extent to which the student accepts and incorporates himself into the pecking order of the white medical system.
For the white student the required self- effacement is some what bothersome but accepted as a tradition which is temporary and certainly no more
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of a hardship than a fraternity hazing. For the Black student, the requirement of subservience is a moral crisis of the greatest importance.
The request and requirement of Black people, in general, to be subservient is institutionalized into the racism of the society as the "Negro in his place; thus even the slightest wilfull concession by a Black student of being subservient to a white throws on to the balance, not only the question of the individual Black student's dignity and self- image but the dignity of the entire Black race. Worse yet, the real pressure to conform to the system comes with introduction into the wards in the union as senior years, coincident with that very time the Black student is evolving through the period of his greatest identity-role image crisis.
As previously demonstrated the resolution of this one particular conflict results in the overwhelming number of Black medical students with emotional problems and all the attendant symptomatology. Furthermore, there is irony in the fact, that in medical school the students are being punished for dysfunctional behaviors that were highly functional in leading to their acceptance into medical school. In other words, unless the students had incorporated very early "rebelliousness" and "hostility" toward peers, relatives, grammar school through college faculty and guidance counselors who tried to persuade them to "know and keep their place" they would not now be in medical school.
Retention and Promotion, A Problem of Attrition
The crisis of attrition or retention and promotion of Black medical students are problems of the
Cognitive and Motoric Domains.
Relevant to analysis of problems within the motoric domain is a multiple regression tabulation, by the SNMA, including thirty-five (35) variables.43 The multiple regression equation included all the personal and institutional variables used by admissions committees in selecting matriculating medical students, white and non-white. Each variable was equated to success as a dependent variable for each category. Correlation coefficients were derived and a correlation matrix was formed. The multiple regression equation was computed in order of importance of the various variables.
Of greatest significance, for the variables used, as a prognosticator of successful promotion for both Black and white medical students was the MCAT science score. However, on the average, the MCAT science score achieved by Black students has only been 78% of the score achieved by white students.
When the relative difference in scores is translated into relative difference in successful retention and for promotion or attrition we find that of all white students who began their freshman year in 1970, 99.3% were retained as matriculates at the end of the year, but .6% of those retained were asked to repeat the year. In 1971, of the original white freshman students, 97.7% were retained, and .6% were asked to repeat the year.
However, for Black freshmen medical students 1970, 95.9% were retained at the end of the year but a horrendous 14.4% were asked to repeat the year. The situation in 1971 showed no improvement in the figure of 8.4% being asked to repeat the year, when
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the total number retained had dropped to 93.2%44
The sole encouraging insight in these figures is the destruction of the myth that Black students have an inability to defer gratification or have little tenacity in the pursuit of their degrees. The figures prove that even in the face of overwhelming adverse circumstances and high non- promotion rates, Black students are quite committed and do persist regardless of time required in grade.
The enumeration of all the solutions prosed to decrease the cultural barriers which hinder Black students from working most efficiently in pursuit of their medical degrees is too massive a task for this document. A selected list of the more recurrent themes will be presented, however.
Far above all else, the student must be provided a suitable climate within which to grow. The environment must result, not from meaningless policy statements of goodwill, but from actual policy which includes:
Admission of sufficient numbers of Black students in each years classes to insure the enrollment of a critical mass of Black students, throughout the four years, as well as within each class.
Adequate non-white faculty should be hired to insure the greatest possible input on all departmental and hierarchical levels.
During the summer before the Freshman year, non-
white students should be required to attend enrichment
courses with as realistic as possible attention to
attention to actual medical classroom life.
The enrichment programs should also include self-awareness group-awareness experiences with faculty, students and administrative staff working in groups to make all feel more responsive to their own needs and to the needs of the patients.
Academic reinforcement and evaluation programs should include internal audit mechanisms such as objective assessment of faculty members to identify possible patterns of alienation with non-white students.
Each medical school should plan programs (forums, rap sessions, retreats, etc.) to sensitize faculty and administration to instructional behavior patterns, in both basic science and clinical teaching situations, which significantly contribute to the alien nature of the medical school setting for non-white students.
Mutual orientation of non-white students and the white school community to the institutional objectives of the school and definition of school- student accountability between students and schools.
The defining process must include:
-definition of all class requirements and criteria on which the students' progress will be evaluated;
-explanation of the minimum grade levels and favorable staff evaluations required to progress through the curriculum;
-establishment and clear
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explanations of the avenues of "resources" available to the non-white student feeling unfairly evaluated or prejudicially treated in class;
-establishment and clear definition of school procedures for formal, early, and continued feedback on academic performance of all students.
Mutual accountability must include:
-clear identification of non-white students' academic responsibilities and social responsibilities, as described in academic codes, codes of conduct, house regulations, etc.;
-clear definition of schools' responsibility to provide minority students with:
Counseling and advisory services should be staffed by Black personnel. If Black personnel cannot be incorporated into established counseling services on a long term basis, then Black consultants should be called.
Each school should establish formal channels of
student/school communication and redress as structurally appropriate in each school, with specific
-investigating charges of racist behavior on the part of white students, faculty and
-Investigating charges to non-white student misconduct between white and non-white individuals face-to-face;
-convening, as appropriate, student-faculty- administration meetings to discuss and take action on specifically racially-oriented incidents occurring in or out of class.
Formal channels should be established between administration/faculty/non-white students, to:
-Personally orient the student and the professor who will teach him his academic difference as defined during the admissions process;
-continually assess the students' successful progress through the curriculum on the basis of his own as well as his professors' perceptions and assessment of his class experiences.
White faculty must learn how to effectively reach non-white students; they should be the first to "over-extend the initiative" if need be.
White faculty must learn how to handle possible racist behavior between individual students in class, including recognizing possible pressure- points such as ridicule, segregation or clustering, excessive competition etc.
Schools should commit themselves to initiating regular evaluations of their special programs and regular procedures concerning non-white students, to be conducted by evaluators or national organizations
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outside the school itself - th SNMA, NMA, for example.
Schools should take the maximum, most creative advantage of the non-white students and faculty within them to help reflect the non-white experience at as many different levels of the school community as possible.
Neither the burden of proof nor the recognition of problem within medical school is the responsibility of the non-white medical student. The administration and faculty must avail to their responsibilities of assuring that acceptance correlates with graduation.