Gender and Racial Discrimination During Residency Training: Scoping Review

Introduction

Background

Gender and racial discrimination continue to be prevalent across society, especially within occupational settings, where most people report experiencing discrimination [1]. Discrimination refers to an “action, behavior, decision, or omission that treats a person or a group of people unfairly” due to traits such as race or gender [2]. These biases can be explicit or implicit but are more often implicit, as reported in the current literature [3,4]. Additionally, these instances of discrimination can range from occurring within individual interactions to institutional policies that marginalize groups of people, such as women and visible minorities (VMs) [5]. VMs refer to “persons, other than Aboriginal peoples, who are non-White in color” [6]. Within health care, many studies surveying physicians have found that women physicians and physicians of VM status report higher rates of patients refusing their care due to their race and/or gender [7,8]. Both women and VMs are also more likely to be mistaken for nurses [8] or as maintenance and housekeeping staff [9]. In addition to these forms of discrimination, some individuals face prejudice stemming from the intersection of their gender and race, known as intersectionality [10]. Intersectionality is defined as “the interaction between gender, race, and other categories of difference in individual lives, social practices, institutional arrangements, and cultural ideologies, and the outcomes of these interactions in terms of power” [11]. An example of what intersectional discrimination could look like within health care can be seen in a study conducted by Pololi and Jones [12], where they interviewed women who were medical faculty regarding their experiences. Women of VM status reported how their double minority status impacted them in the workplace, especially how isolating it felt to be the only woman and/or person of VM status on the faculty [12].

Medical residents hold a unique position within health care, as they are simultaneously trainees and practitioners interacting with and caring for patients under supervision. Recent research conducted by Mocanu et al [13] surveyed general surgery residents on the effects that their gender and/or VM status had on their resilience and their residency training experience. Some experiences of discrimination reported were similar to those reported by physicians, such as how the majority of women residents and residents of VM status faced dismissal of their medical advice by patients due to their gender or race [13]. Residents also believed that they received fewer training opportunities due to their gender and/or race [13]. Another study conducted by Bhatt [14] found that women or men of VM status were rarely selected as chief residents; often, they were White men, even though residents are a diverse group. Residents also described being doubly discriminated against due to their gender and race [14].

Although individual research studies have been conducted on the experiences of residents facing discrimination, to the best of our knowledge, this is the first paper that compiles resident experiences of discrimination into 1 paper. This scoping review aims to explore and analyze existing literature on the impact of gender and racial discrimination on residents.

Positionality Statement

We acknowledge that our perspectives and identities may have influenced our scoping review. However, through reflexivity and debriefings as a team, we have examined potential preconceived assumptions and strived for an accurate and rigorous representation of the existing literature. The team includes diverse members. IJ is a woman from a VM group and a graduate research assistant on the project. LD is a White female librarian who conducted a comprehensive search for this scoping review. JN is from a VM background and is a research assistant. MR is a VM woman and a scholar in medical education whose work focuses on the experiences of structurally marginalized learners.

Methods

Overview

We used the Arksey and O’Malley [15] framework, which consists of 5 steps: identifying the research question, finding relevant reports, selecting reports, extracting data, and summarizing the results. Furthermore, for our data reporting, the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were used to ensure transparent and clear reporting of the included studies in our scoping review [16]. Additionally, the protocol for this scoping review was developed in accordance with these guidelines [16]. The protocol has not been registered.

Study Eligibility Criteria

Included studies focused on medical residents who faced both gender and racial discrimination during their residency training. We included peer-reviewed studies, books, book chapters, peer-reviewed abstracts, dissertations, and papers written in English. Papers that explored the experiences of other populations, such as undergraduate medical students, fellows, clinical and academic faculty, health care professionals, or allied health care professionals, were excluded. Papers that did not align with our study objectives were excluded. Studies that focused solely on collecting data on gender or racial discrimination were not included, as the purpose of this scoping review was to explore the experiences of residents who faced discrimination based on both gender and race. Literature surrounding the impact of discrimination on resident assessments and evaluations was excluded, as there are abundant studies and reviews regarding this specific topic. We also removed studies focused on sexual orientation, as it is not the focus of this review and is a large topic in its own right. Studies that were not conducted in a residency setting were excluded. We also excluded the following: policy documents, vlogs, websites, working papers, newsletters, government publications, videos, study protocols, and papers written in other languages. There were no limitations imposed on the study design, the time frame, or the countries where the research was conducted.

Search Strategy

A health sciences librarian (LD) and other research team members collaborated to develop an initial search strategy to identify studies on the experiences of medical residents with intersectional gender and racial discrimination. The health sciences librarian then ran the search in the following databases: Ovid Medline(R) ALL, Embase (via Ovid), APA PsycInfo (via Ovid), CINAHL Plus with Full Text (via EBSCOhost), and Scopus from inception until May 2, 2025. The strategy combined keyword and subject heading search terms for four concepts: (1) medical residents; (2) gender or gender identity; (3) race, ethnicity, or foreign; and (4) bias or discrimination. The concepts were combined with Boolean AND, so all 4 concepts had to be present for a paper to be retrieved. Conference abstracts were removed. The full search strategy is provided in Multimedia Appendix 1. All search results were loaded into Covidence (Veritas Health Information) for deduplication and screening. Reference lists from all included studies were reviewed to identify additional relevant studies.

Study Screening

Reports were screened through a multiphase process. Two researchers reviewed the first hundred papers, and the kappa coefficient was calculated to assess their agreement. We obtained a kappa of 0.72, indicating substantial agreement. Subsequently, all papers were screened based on title and abstract by 2 independent reviewers (IJ and JN), who either included or excluded each paper. A third reviewer (MR) resolved any discrepancies. During the full-text review phase, the 2 reviewers (IJ and JN) made the final decision to include or exclude each paper from the scoping review. Any discrepancies were resolved through group consensus.

Data Extraction

Study content was extracted using Microsoft Word to create tables for organizing and managing the information from the included studies. We extracted authors’ details, the country where the studies were conducted, publication dates, sample sizes, research methods or study designs, and disciplines (Table 1). Additionally, we extracted study aims or objectives and findings. Two reviewers (IJ and JN) extracted data from all included studies, and a third reviewer (MR) double-checked the content and entries for accuracy, ensuring no data was overlooked. Any inconsistencies were resolved through group consensus. A quality appraisal of these reports was not performed, as it is not a requirement for scoping reviews [16].

Synthesis of Results

Data were analyzed using conventional content analysis, a suitable approach given the lack of predefined categories. Content analysis allowed us to identify the main categories, relationships between them, and gaps in the literature. One team member (IJ) created data abstraction tables before data abstraction began. These abstraction forms included citation details, such as author, year of publication, title, and country of study, as well as study characteristics, such as study design, research objective, and sample size. Two team members (IJ and JN) coded the data and organized it into 4 themes. Any discrepancies at this stage were resolved through consensus.

Ethical Considerations

This is a scoping review that synthesizes published papers; therefore, no human ethics approval was required.

Results

Description of Included Studies

The initial search identified 4637 potential studies, of which 2435 remained for title and abstract screening after duplicates were removed. A total of 340 papers were selected for full-text review, and ultimately, 24 papers met the inclusion criteria. Reviewing the reference lists of the included papers uncovered 2 additional relevant reports, bringing the total to 26 studies included in the scoping review (Figure 1).

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An overview of the characteristics of the included studies is provided in Table 1. These papers were published between 1995 and 2024. Most studies (n=16) were conducted in the United States, followed by Canada (n=4), Australia and New Zealand (n=2), and 1 study each from Saudi Arabia, Mexico, South Africa, and the United Kingdom. Fourteen papers used a quantitative study design, followed by 6 qualitative studies, 3 mixed-methods studies, 2 personal accounts, and 1 commentary. Of the 23 research studies, sample sizes ranged from 8 to 7409. Residents came from a variety of specialties, including mixed specialties (n=8), surgery (n=5), internal medicine (n=3), anesthesiology (n=2), emergency medicine (n=2), orthopedic surgery (n=2), otolaryngology (n=1), family medicine (n=1), neurosurgery (n=1), and psychiatry (n=1).

Our data analysis revealed four themes: (1) forms of discrimination faced by VMs, (2) sources of discrimination, (3) ramifications of discrimination, and (4) ways to reduce gender and racial discrimination (Table 2).

Theme 1: Forms of Discrimination Faced by VMs

Twenty-three (88%) studies highlighted the different ways discrimination has manifested against VMs [13,14,17-24,27-36,38-40]. Eighteen papers described instances of microaggressions that were experienced by women and VM residents [13,14,17-22,24,28-32,34,35,38,40]. Participants in 11 studies reported experiencing misidentification of their role due to their gender and/or race [13,17-20,22,24,29,31,32,34]. Most residents who were assumed to be a nonphysician or a non–health care worker were women [13,17-20,22,29,32], of VM status [18,19,24,31,34], or both [18,24,32]. Women were more likely to be assumed to be a nurse or secretary [20,22,29], while VMs were more likely to be assumed to be custodial staff [24,29]. Moreover, residents experienced misidentification even after introducing themselves and wearing a white coat and stethoscope [34]. However, residents were aware that misidentification likely occurs due to stereotypes [29]. In addition to misidentification of role, VMs also reported being mistaken for another resident of minority status [20,31,34] and having patients ask to see a physician of another race [22,29,30].

VM residents in 10 papers also reported experiencing verbal microaggressions [17,20-22,24,29,31,34,35,40], including hearing racial slurs [17,31,40], receiving questions about their ethnicity [22,34], and astonished comments on their English proficiency [17,22], such as “Well, at least you speak good English!” [17]. The majority of these microaggressions originated from patients; however, attendings and other health care workers were a close second [21,24,29,31,34,40]. VMs were also discriminated against for their accents, often being treated with less respect as a result [14,28,30].

Another frequently reported form of microaggression across 5 studies was that VM residents were assessed using different standards than their non-VM coresidents [14,17,21,24,31]. This disparity manifested as harsher evaluations [17,21] and more critical feedback on performance [24].

Most gender-based microaggressions occurred against women. For example, women residents in 3 papers were more likely to report facing discrimination due to pregnancy and childcare than men residents [14,27,33]. These included women being asked about their family plans during residency interviews, being treated differently while pregnant during residency, and facing a lower chance of receiving a promotion [14]. Additionally, many faculties discouraged women from entering competitive disciplines, such as surgery, due to these specialties being considered labor-intensive and incompatible with family responsibilities [14,22,28]. Women were also more likely to face discrimination from other women, attending physicians, and nurses [14,22].

Furthermore, many studies recognized that microaggressions were compounded and worse for women of VM status [13,14,18,22,24,31,32,35]; however, only 3 studies investigated resident experiences with an intersectional lens [13,14,22]. One study found that VM women were less likely to feel that they had a good relationship with their staff [13]. Another study found that Black, Asian, and minority ethnic women often felt sidelined by men and found it overwhelming to respond to every instance of discrimination [22].

Another form of discrimination that was reported less frequently but consistently over the years is sexual harassment, which was primarily reported by women in 10 papers [20,22,27-29,33,35,36,39,40]. Inappropriate sexual comments [20,22,28,29,35,36] and unwanted sexual jokes [22,35,40] were the most commonly described, followed by sexual advances [36,40]. Other instances of sexual harassment include unwanted attention and disrespectful body language [36].

Theme 2: Sources of Discrimination

Fourteen (53%) papers explored who contributed to the discrimination experienced by VMs and women [17,20,22,24,27,29,31,33-37,39,40]. Our literature review found that VMs experienced discrimination from a multitude of perpetrators. These include, but are not limited to, patients, families, attendings, peers, nurses, and other health care professionals [17,20,22,24,27,29,31,33-37,39,40].

Participants in 12 studies reported patients and patients’ families as either the main or the second most common perpetrators of discrimination [20,22,24,27,29,31,33-36,39,40]. Of those who reported patients as the main source, these experiences of discrimination were both racial [20,22,24,27,29,31,33,34,39,40] and gender-based [27,29,33,39]. Patients were also the most common cause of sexual harassment against women residents, followed by staff, including attending physicians and nurses [20,27,29,33,39,40].

Eight studies reported that attending physicians were another major contributor to the racial [17,24,29,33-35,39] and gender [33,35,36,39] discrimination experienced by VM residents. Attending physicians were also found to be a major cause of sexual harassment [33,35,39], with 1 paper reporting them to be the main perpetrators [35]. They highlighted the negative impact this can have on residents, as these attendings are often their mentors who serve as guides for their education and, therefore, can influence resident learning environments [35]. Eight papers described how VM residents often experienced discrimination from nursing staff and other health care workers [17,22,27,31,33,34,37,39]. Only 4 papers mentioned peers and colleagues being a cause of discrimination [17,33,34,39].

Theme 3: Ramifications of Discrimination

Twenty-one (80%) papers found that participants experienced the ramifications of discrimination in a variety of ways, with many papers exploring the effects of discrimination and how they manifest [13,14,18-22,24,26-31,33-38,40]. A major consequence of discrimination was residents being reluctant to report their experiences [13,14,22,28,29,34,35,40]. Many participants described being afraid that reporting these instances could have repercussions for their professional career [22,29,34,35,40], especially for those who experienced discrimination from senior colleagues and leadership [22,29,34]. Participants also avoided reporting incidents because they did not have the time and energy to do so [14,22,29,34]. Some residents mentioned being worried that their efforts to report would be wasted, as their experiences would just be swept under the rug [13,34,40]. Residents also felt that their experiences were not significant enough to report [22,35,40]. One paper mentioned residents being worried that their report would be perceived as playing the “race card” [34].

Five papers found that learners experienced burnout due to discrimination [18,19,29,31,33], with 1 paper reporting that learners felt more fatigued and exhausted on top of their current program workload and expectations [29]. Four studies spoke about the feelings of loneliness [21,24,28,34], with extreme cases of learners experiencing feelings of being “othered” [21,24]. Discrimination also caused some residents to have suicidal thoughts [23,27,33], with studies finding an association between mistreatment exposures and the number of suicidal thoughts [27,33]. Learners also reported that discrimination caused them to feel the need to suppress their feelings, resulting in residents ignoring the incident altogether [29,30]. A few residents mentioned internalizing messages of discrimination [20,22], making them feel less competent in their clinical abilities [22] or feeling the need to hide their culture [20]. Residents who experienced discrimination reported poorer learning environments [35,38]. Similarly, in 1 study, residents who did not experience discrimination were more likely to rate their academic satisfaction [26] highly. As a result, many women and/or VM residents mentioned contemplating withdrawing from their residency program or quitting entirely [13,31,35,36,40].

Theme 4: Ways for Individuals and Institutions to Reduce Gender and Racial Discrimination

Nineteen (73%) studies discussed and provided potential solutions for reducing gender and racial discrimination experienced by residents [13,18,19,21-25,27-29,31,32,34-37,39,40]. These recommendations ranged from educational interventions that could support residents to changes that could be implemented at the institutional level.

Many papers recommended various curricular and training changes to reduce discrimination [18,19,21-23,27,29,31,32,35,39,40]. These included providing training on what explicit and implicit biases are and how to recognize them [18,19,21-23,27-29,32,35,40], as well as incorporating training on how to respond and intervene during instances of discrimination [18,19,22,27,29,31,39]. In addition to training residents, some papers suggested providing faculty and other health care professionals with these educational opportunities as well [18,21-23,29,32,35].

Several studies also proposed increasing the number of women and underrepresented minorities in faculty and leadership positions as a way for institutions to foster an inclusive environment [13,21,25,28,34]. Many participants believed that hiring more minorities into positions of power would allow more residents access to mentors who could provide the support and resources they need while facing challenges in residency [13,21,25,28,34].

Some papers suggested that institutions should set policies to improve working conditions for women and VMs. These included encouraging residents to report incidents when they occur [22-24,31,35,36,40] and keeping them safe from retribution [23,24,36,40] by using a confidential reporting system [36]. Another suggestion was to implement policies that required residents to refer offending patients to other physicians, thereby allowing residents to work in a safe environment while ensuring that patients received the care they needed [22].

Discussion

Principal Findings

The purpose of this scoping review was to explore and highlight resident experiences of gender and racial discrimination to raise awareness of the impact of these experiences on residency training programs. The findings revealed that residents predominantly reported experiencing microaggressions, misidentification, and sexual harassment from multiple sources, including attendings and other health care workers. These experiences frequently had negative repercussions, including adverse effects on residents’ feelings of competency.

Educational Impact of Microaggressions

Discrimination experienced by VMs is an ongoing issue that has plagued the health care system for a very long time. Microaggressions are becoming an increasingly common form of discrimination experienced by residents and physicians of VM status [2,34]. Several studies allude to discrimination toward medical trainees as part of their training due to factors such as hierarchy [41,42]. A recent study by Gianakos et al [43] found that the majority of incidents reported by residents in the study were perpetrated by supervising attendings and their senior coresidents. Similarly, our analysis found that attendings were the most common source of discrimination, second only to patient interactions. Microaggressions from attendings and other senior colleagues can have serious and lasting consequences for residents, particularly with respect to career trajectory. The impacts of these microaggressions on future careers can start well before residency; for example, many women reported being discouraged by faculty from entering competitive specialties in residency, such as surgery, preventing these disciplines from becoming diverse [14,22,28]. Furthermore, microaggressions that occur during residency also impact resident careers. For instance, our findings indicate that residents from marginalized communities are commonly subjected to higher standards and are more likely to receive harsher evaluations than their non-VM peers [21]. Such discriminatory feedback can negatively affect residents’ progress during training and may also discourage them from pursuing careers in academia [44]. Additionally, several papers reported that residents expressed concern about receiving fewer opportunities based on their gender and/or race [13,18,19,22,35,37]. Residents may also lack sponsorship and general support from attending physicians, which can limit access to career-advancing opportunities, including employment at prestigious academic institutions [44]. Consequently, fewer women and VMs attain leadership positions, resulting in reduced availability of mentorship and advocacy for marginalized residents [13,21].

Similar patterns have been observed among faculty physicians. Faculty identifying as VMs report feeling pressured to meet higher performance standards than their non-VM colleagues to maintain their positions or advance professionally [45]. This differential treatment may further contribute to the underrepresentation of VMs in senior academic and leadership roles [45].

Intersectionality

The compounded effects of discrimination faced by residents with intersectional identities were acknowledged in many papers; however, they were not explored in depth. Learning about the unique experiences of residents who face discrimination due to both their gender and race is essential for developing solutions, since these issues cannot be resolved by addressing gender or racial discrimination alone [13]. The intersectional experiences of physicians described in the literature are similar to those reported by residents. A study that interviewed Black female physicians found that many of them felt isolated from their colleagues and patients, similar to how residents were less likely to feel connected to staff [13,46]. Physicians also described feeling burdened with high expectations due to their race and gender, while many did not expect them to succeed [46]. More qualitative studies on the intersectional experiences of residents are necessary to reveal how they may differ from or relate to physician experiences.

Strategies for Reducing Discrimination and Microaggressions

Many papers within this scoping review proposed strategies for reducing gender and racial discrimination against residents. Although many papers recommended incorporating training on discrimination and intervening in situations of microaggressions, none of the papers mentioned implementing these suggestions within their institutions or evaluating the impact of these solutions on resident experiences. It is important to highlight that this is a notable gap in the literature, as there are many studies describing discrimination and possible solutions for reducing these experiences, but very few studies that assess the efficacy of these recommendations. A study conducted by Mullett et al [47] focusing on equity, diversity, and inclusion curriculum development for pediatric residents revealed that when residents were exposed to training sessions on microaggressions, their knowledge and awareness about microaggressions in a clinical setting increased. Additionally, the residents were able to propose effective strategies to deal with microaggressions.

In addition to providing educational opportunities for residents, several papers suggested training faculty and leadership about discrimination [18,21-23,29,32,35] and how to respond and intervene during these situations [22,27,31]. Including staff and faculty in these educational sessions could motivate witnesses to intervene when an incident related to discrimination occurs [22,27,31]. Similar to the literature on residents, there is limited research evaluating the impact of such interventions on faculty. Gleeson et al [48] described the development and outcomes of a diversity, equity, and anti-racism curriculum implemented at their medical center. The curriculum aimed to raise awareness and equip physicians and trainees with skills to recognize racism through didactic sessions and interactive workshops. Although participants reported increased knowledge and rated the sessions as impactful, survey data collected longitudinally showed no change in the institutional discrimination experienced by participants or by individuals they knew.

Another strategy for decreasing discrimination was to increase the number of women and VMs in leadership positions, particularly for expanding the number of mentors and role models available for residents [13,21,25,28,34]. Mentorship is considered to be one of the most significant aspects of residency that can greatly impact a resident’s experience, and studies show that women of VM status are the least likely to have a mentor during residency [13]. In addition to mentorship, VMs recruited into positions of leadership would be more likely to be advocates for residents who identify as women and VMs [21].

Implications

Findings from this scoping review generated new perspectives and knowledge to better understand how race and gender can combine to impact resident experiences. This scoping review illuminated areas of postgraduate medical education that need change and highlighted additional actions required to enhance resident experiences. Understanding how gender and racial discrimination intersect and manifest at the postgraduate level can aid programs in developing a tailored response to these challenges. Improving resident experiences and supporting them in addressing these issues can positively influence their interactions with colleagues and patients, leading to improved patient care. Additionally, raising awareness of this topic can educate residents, physicians, and other staff, fostering better treatment of colleagues based on their gender and race. The results of this scoping review will contribute to postgraduate medical programs evaluating their curricula and refining or incorporating training on discrimination within existing programs.

Strengths and Limitations

This scoping review was based on a rigorous search and methodological process. The search strategy included many synonyms and was adapted for 5 databases. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting checklist, which added to the rigor of our scoping review. However, some limitations should be acknowledged. We did not impose date restrictions because we aimed to examine how residents’ experiences with discrimination may have changed over time. However, it is important to note that the composition of the resident workforce has evolved substantially during this period, particularly with an increase in the proportion of women in medical training. Although insufficient historical data precluded direct comparisons across earlier periods, our findings suggest that residents’ experiences of discrimination have remained largely similar over time. Some studies may have been overlooked due to our search being limited to papers in English. Additionally, although we examined studies from different countries, our findings may not be generalizable to all residency programs due to differing societal contexts, varying norms, and possibly different training structures.

Conclusion

Findings from this scoping review describe the different ways women and VM residents often face discrimination, who perpetrates it, the consequences it may have on learners, and steps that individuals and institutions can take to reduce discrimination. Even though residents have been reporting experiences of gender and racial discrimination for many years, discrimination continues to be a persistent and ongoing issue in many residency programs. Learning about and raising awareness of resident experiences can assist institutions and residency programs in developing tailored solutions, especially for those who face intersectional discrimination.