Countless barriers contribute to the lack of workforce diversity. Structural racism, however, acts a significant driver of this problem. While frequently described as a resolved issue for the United States, examples of racism and racist actions continue to proliferate in the first two decades of the 21st century (7). The response to Hurricane Katrina in New Orleans (8). The “cost-saving” impetus for the water crisis in Flint, Michigan (9, 10). The death of Ms. Sandra Bland while in the custody of Texas police (11, 12). In South Carolina, church executions by a white supremacist (13). Building an access pipeline in South Dakota on territory of Indigenous people (14). Arson of three Black churches in Louisiana by a young white man who admitted to being influenced by rhetoric of a far-right musician (15). Mr. Ahmaud Arbery murdered by three white men for jogging in their south Georgia neighborhood (16). Punitive immigration policies that separate children and their families. (17). Onlookers watching for more than eight and a half minutes as Mr. George Floyd, pinned to the ground by a Minneapolis police officer, cried out “I can't breathe” more than 20 times before he died (18). Each representing a horrific event in isolation, but structural racism acting as the common thread binding these incidents together.

Amid these repeated acts of racialized violence and terror, BLNA faculty and trainees carry on with the demands of their roles as if none of it creates anything amiss in their lives. They continue to care for patients. They keep studying for exams that determine competency in their respective specialties. Meeting these required expectations does not imply that they are impervious to the heaviness of heartaches felt in their communities and portrayed by the news. The biases of others that draw greater scrutiny and criticism of their intellectual abilities and their clinical acumen add insult to the injuries. To persevere, they attempt to reconcile their membership in a profession that simultaneously provides gratifying purpose and expects them to diminish or outright dismiss the detrimental effects of social injustices and structural racism all around them. They persevere by learning and practicing in academic and sociopolitical climates that promulgate chaos and disruption in their lives.

In the 1960s, Stokely Carmichael introduced the term institutionalized racism. In an excerpt from his piece in The Massachusetts Review, Carmichael writes “When unidentified white terrorists bomb a Negro church and kill five children, that is an act of individual racism, widely deplored by most segments of the society. But when in that same city, Birmingham, Alabama, not five but five hundred Negro babies die each year because of a lack of proper food, shelter and medical facilities, and thousands more are destroyed and maimed physically, emotionally and intellectually because of conditions of poverty and deprivation in the ghetto, that is a function of institutionalized racism” (19). In 2000, Dr. Camara Phyllis Jones published “The Gardener's Tale,” an allegory of a gardener with two flower boxes of different colored flowers (20). Her allegory illustrated the different levels of racism working within society (Figure 1). The gardener develops a preference for the red flowers growing in the rich soil, convinced that red flowers were intrinsically better than pink ones, all while doing nothing to improve the poor, rocky soil in which the pink flowers attempted to grow. Dr. Jones used her allegory to explain how institutionalized racism generated associations between socioeconomic status and race through the discriminatory practices that created racialized differences in access to education, housing, employment, and voting rights. Subsequently, these factors adversely affect healthcare and health outcomes, in part, by derailing efforts to build and sustain pathways to professional development for the medical profession.

Historically, the medical profession has perpetuated racialized biases and racist practices through its established systems, policies and hierarchies of power. Written in 1910, the Flexner Report received acclaim for revolutionizing medical education (21). Its recommendations also devalued Black people and further perpetuated racial biases. The author, Abraham Flexner, maintained that Black physicians were assigned to “keep [African-Americans] healthy enough not to contaminate nearby White people” (22). In his view, historically Black medical schools should focus on hygiene for Black people, rather than introducing students to surgery and comprehensive medical care for their patients. That type of training was reserved for white people. This widened the racial chasm in medicine and led to the closure of all but two of the seven Black medical schools operating at that time (23). Although the Carnegie Foundation sponsored the report and supported its findings, the Foundation effectively turned its back on the two remaining Black medical schools—Meharry and Howard—when they sought funding to help implement the [costly] recommendations from the Flexner Report. In response to their requests, the Foundation replied, “If we start helping medical colleges for colored people we cannot discontinue.” (24).

As a consequence, people from minoritized and marginalized communities disproportionately experienced disenfranchisement and health inequities. Early medical professionals asserted that Black patients had “natural immunity” to certain diseases or manifested diseases differently because of their race. These notions provided the backdrop for spreading misinformation during the outbreak of yellow fever in Philadelphia and were the basis for the Tuskegee Study of Untreated Syphilis in the Negro Male, one of the longest, non-therapeutic experiments in medical history (25, 26). Over the course of 40 years (1932–1973), the study observed 400 men to document any “racial differences in clinical manifestations of syphilis” (26).

In the 1950s and 1960s, the forced sterilization of Puerto Rican women occurred due to a U.S. government sanctioned mass-sterilization policy (27). More than historical footnotes, the racist beliefs that drove these and other justifications for mistreatment of BLNA people persist in science and medicine. Ignorance and inaccurate presumptions about racial differences influence current clinical practice, institutional culture and medical education curricula. For example, racialized disparities in pain assessment and management are thought to be deeply rooted in myths that Black people have higher tolerance for pain than white people because of their “thicker skin” (28, 29). Despite alarming inequities in health outcomes for Indigenous people, there are persistent disparities in personal health care expenditures by Indian Health Services compared to U.S. National Healthcare expenditures (30).

In 2020, the American Academy of Pediatrics (AAP) issued an apology for its history of repeatedly barring the acceptance of Black physicians as members and supporting concessions of their membership due to race (31). The experiences of Drs. deGrate Smith and Scott also included exclusion from their local chapter of the American Medical Association (AMA). Without membership or certification from the AMA, Drs. deGrate Smith, Scott and countless others were unable to care for their patients without disruption; neither could they contribute to the medical policies that affected their patients (31). The longstanding history of segregation and exclusion within the AMA was one of many reasons for the founding of the National Medical Association, the nation's largest and oldest organizations dedicated to African American physicians and their patients since the late 19th century (32). About 75 years later, the Association of American Indian Physicians formed to address the ongoing health disparities faced by Native American communities (33). The formation of the National Hispanic Medical Association in 1994 demonstrated the ongoing need for minoritized and marginalized physicians to advocate for health equity within their communities (34).

When considering the historical and ongoing barriers to increasing the number of physicians underrepresented in medicine, the 5:1 ratio of Black trainees to Black faculty exemplifies the amount of work necessary to dismantle structural racism in medicine that remains undone (35). Statements of solidarity alone cannot translate into tangible investments toward solutions for these long-standing issues. Although responding to sociopolitical unrest and multiple crises triggered by racist and divisive rhetoric now appears trendy and short-lived for far too many in the majority, BLNA faculty wrestle with the distress these issues create within and outside of the academic or clinical environment. BLNA mentees experience isolation and lack of support. They need and deserve the benefits produced by concordant racial/ethnic faculty mentoring. However, emotional, mental and physical exhaustion as a negative consequence of engaging in these efforts can adversely impact academic productivity and advancement among the BLNA faculty, who incorporate an often out-sized proportion of mentoring responsibilities into their professional portfolio. Furthermore, experiences with invalidation by other faculty members can interrupt, mar or derail the careers of BLNA faculty.

BLNA faculty learn to maintain a balance between the despair and the data, the sympathy and the statistics and even the rage and rational. With that clarity, research into evidence-based methods for solutions to the problems of underrepresentation ought to highlight BLNA faculty and amplify their lived experiences within the profession. Leaders of academic medicine need to welcome opportunities to learn how BLNA faculty navigate the labyrinth of shielding the burdens of their emotional vulnerabilities; providing an academic discourse to justify the reality of their experiences; and even proposing data-driven, solutions. Understanding the labyrinth can improve the profession of academic medicine and potentially spark innovations that improve patient care.

Although some accept the concept of structural racism, many struggle with addressing the racism driving racialized mistreatment. Use of racial quotas and affirmative action programs have repeatedly failed to reconcile racialized disparities in progress. The Bakke decision—Regents of the University of California vs Bakke (1978)—exemplified the vitriolic backlash against quotas and affirmative action programs benefitting BLNA people (36). This Supreme Court case also exposed deeply entrenched, biased opinions that increasing racial and ethnic representation required medical schools to lower their standards and accept less qualified students (37). The prevailing presumption held that these practices displaced more qualified and worthy white students (37, 38). Almost 45 years later, the biases persist, and schools struggle to differentiate evidence-based holistic review practices from misguided arguments linking affirmative action programs to reverse racism and outdated notions of racial quotas (39–41).

Alternatively, efforts explicitly aimed at restitution begin with acknowledgment and acceptance of the pain and suffering created by racism and endured for decades by minoritized and marginalized communities. Structural racism exists everywhere, including within the medical profession. Implicit white race preference can adversely influence actions to diversify medicine (42). Intentional efforts to mitigate racialized bias; recruit a diverse pool of applicant; and establish evidence-based initiatives for holistic review of applicants hold promise (39, 41, 43, 44). Academic medicine must also heed the ongoing calls to develop anti-racist policies and build a racially/ethnically diverse workforce through optimization of professional pathways. To accomplish these directives requires nurturing an environment that prioritizes inclusion, belonging and equity at its institutions.

Despite comprising almost 15% of the population, only 7% of medical students and trainees are Black. More alarmingly, only 3.6% of full-time medical school faculty are Black (45). From generalists to specialists, over the past few decades, physicians from groups URiM comprise a meager percentage of faculty in their specialties, and growth lags behind the proportion of women in medicine (46–48). Moreover, far fewer URiM faculty achieve the rank of associate or professor (46, 47).

Even more telling is the outsized role of Historically Black College and University (HBCU) medical schools in producing Black physicians. If only two of the other five Black medical schools had remained opened after 1910, an estimated 10,000 additional students would have graduated from them between 1910–2019 (23). Assuming similar rates of growth as Meharry and Howard, the four (theoretical) schools would account for an 11% annual increase in the number of Black medical graduates, instead of the 1% increase currently observed (23). Given the present-day consequences of the Flexner Report and related racialized policies, the need for equity-focused interventions is evident (23, 24).

HBCU medical schools account for 33% of Black chairs, 10% of Black faculty and 14% of Black students (49). When examining the data for representation of people that are of Hispanic, Latino/a/x or Spanish origin, the disparities widen. Despite comprising approximately 18% of the U.S. population, barely 10% of matriculants to medical school and only 5.5% of full-time medical school faculty are Hispanic, Latino/a/x or of Spanish origin (2, 3, 50). The data for the Native American community are abysmal (2, 3, 50, 51).

The AAP acknowledged the need to increase workforce diversity to improve concordance with the increasing racial/ethnic diversity of patients served (52). Among possible solutions, they highlighted the role of sponsorship as an important approach to improve representation and advancement of URiMs in academic medicine (52, 53). However, to date, the AAP lacks formally supported, structured mentoring programs that directly and equitably address workforce diversity. On a broader scale, the NIH's National Research Mentoring Network encourages URiMs to pursue careers in biomedical research. The program provides networking, professional development and mentoring activities to address long-standing racial/ethnic inequities in NIH grant funding (54). Yet, it continues to struggle with reversing the lack of racial/ethnic diversity among NIH grant recipients.