Patients, Pride, and Prejudice Exploring Black.97059

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Author: Mpalirwa Joseph MD; Lofters Aisha MD, PHD; Nnorom Onye MD, MPH; Hanson Mark D. MD,
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FRCPC
Title: Patients, Pride, and Prejudice: Exploring Black Ontarian Physicians’ Experiences of Racism and
Discrimination
DOI: 10.1097/ACM.0000000000003648
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Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Academic Medicine
DOI: 10.1097/ACM.0000000000003648
Patients, Pride, and Prejudice: Exploring Black Ontarian Physicians’ Experiences
of Racism and Discrimination
Joseph Mpalirwa, MD, Aisha Lofters, MD, PHD, Onye Nnorom, MD, MPH, and Mark
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D. Hanson, MD, FRCPC
J. Mpalirwa is staff family physician, Casey House, and a member of the Black
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Physicians’ Association of Ontario, Toronto, Ontario, Canada.
A. Lofters is family physician, associate professor, and clinician scientist, Department of
Family and Community Medicine, Women’s College Hospital and University of Toronto;
adjunct scientist, ICES; and a member of the Black Physicians’ Association of Ontario,
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Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-7322-0894.
O. Nnorom is public health and preventive medicine physician, and assistant professor,
Dalla Lana School of Public Health and Department of Family and Community
Medicine, University of Toronto, and president of the Black Physicians’ Association of

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Ontario, Toronto, Ontario, Canada.
M.D. Hanson is a child and adolescent psychiatrist, Hospital for Sick Children, and
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professor, Department of Psychiatry, Faculty of Medicine, University of Toronto,
Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-0820-4521.

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Correspondence should be addressed to Joseph Mpalirwa, c/o Casey House, 119 Isabella
St., Toronto, ON, Canada, M4Y 1P2; email: j.mpalirwa@mail.utoronto.ca.
Acknowledgments: Aisha Lofters is supported as the Chair in Implementation Science at
the Gilgan Centre for Women’s Cancers at Women’s College Hospital in partnership
with the Canadian Cancer Society, and as a clinician scientist with the University of
Toronto Department of Family and Community Medicine. The authors wish to thank
Sophia Oke, MSc—a third-year medical student at the University of Toronto—for her
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assistance with formatting of the manuscript.
Funding/Support: None reported.
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Other disclosures: The authors have no conflict of interests to disclose.
Ethical approval: Research ethics approval was obtained through the St. Michael’s
Hospital Research Ethics Board.
Previous presentations: Research findings were presented as a poster at Learn Serve

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Lead: The 2019 Association of American Medical Colleges Annual Meeting, November
11, 2019, Phoenix, Arizona. Findings were also presented at the Canadian Conference on
Medical Education (CCME), April 14, 2019, Niagara Falls, Ontario, Canada.
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Abstract
Purpose
Black physicians’ and trainees’ experiences of racism are not well documented in
Canada, reflecting a knowledge gap needing correction to combat racism in Canadian
health care. The authors undertook a descriptive study of Black physicians and trainees in
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the Canadian province of Ontario. The goal of this study was to report upon racism
experienced by participant Ontarian physicians in order to challenge the purported rarity
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of racism in Canadian health care.
Method
An anonymous online survey of physicians and trainees who self-identify as Black
(African/Afro-Canadian/African-American/Afro-Caribbean) was administered in March

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and April 2018 through the Black Physicians’ Association of Ontario (BPAO) listserv.
The survey was modeled on qualitative interview guides from American studies.
Snowball sampling was employed whereby BPAO members forwarded the survey to
eligible colleagues (non-BPAO members) to maximize responses. Survey data was

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analyzed and key themes described.
Results
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Survey participants totalled 46, with a maximal response rate of 38%. Participants
reported positive experiences of collegiality with Black colleagues and strong bonds with
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Black patients. Negative discrimination experiences included differential treatment and
racism from peers, superiors, and patients. Participants reported race as a major factor in
their selection of practice location, more so than selection of career. Participants also
expressed a lack of mentorship, and there was a strong call for increased mentorship from
mentors with similar ethno-racial backgrounds.
Conclusions
This study challenges the notion that racism within Canadian health care is rare. Future
systematic collection of information regarding Black physicians’ and trainees’
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experiences of racism will be key in appreciating the prevalence and nature of these
experiences.
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Each country has its own unique history of racism and discrimination within which its
medical education system is situated. This undoubtedly generates nation-specific medical
education priorities, including education research priorities. Acknowledgment of racism
and discrimination towards Black Canadians remains limited (at best) and this is mirrored
within Canadian medical education. Despite the United Nations describing “the structural
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racism that lies at the core of many Canadian institutions,”1 many Canadians believe that
racism is less of a problem today than it was over 25 years ago.2 However, personal
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experiences of racism seem to be on the rise.2 Literature on racism in Canadian health
care education is rare,3-6 but this limited literature may be due to a lack of exploration of
racism as opposed to a true rarity of racism in Canadian health care education.4
Further, Canada’s medical elites are commonly White and unfamiliar with racism and
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consider it uncommon.4 Absence of data reflects a knowledge gap necessary to combat
racism in Canadian health care. In the United States, where there is a more advanced
discourse on racism, medical educators such as Karani et al have challenged educators,
faculty developers, and researchers to identify racism across the professions’ varied
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educational contexts and commit to its undoing.7 In particular, Karani et al recommend
the application of critical race theory (CRT) approaches and frameworks for exploring
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experiences of racism in health professions education.7 Critical race theory “ … values
experiential knowledge as a way to inform thinking and research” because narrative

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accounts are considered important sources of data.8 Accepting their challenge,7 and using
a CRT-aligned approach, we surveyed Black physicians and postgraduate medical
trainees in Ontario to ask: “What are your self-reported health care-related experiences of
racism and what are some of the associated impacts?” Our work is a nascent step in
compiling the descriptive knowledge essential to address racism experienced by Black
Canadians enrolled in Canadian health professions education.
Method
Study setting
The province of Ontario is Canada’s most populous province with over 13 million
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inhabitants and is home to 36% of Canada’s 84,260 active physicians.9 The Black
population, Canada’s third largest visible minority group, comprises 4.7% of the
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population of Ontario.10 However, Black physicians only comprise an estimated 2.3% of
practicing physicians in Ontario.11 The population of Black physician trainees is
unknown.
Study design
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This was an exploratory, descriptive study of Black physicians and physician trainees in
Ontario regarding health care-related experiences of racism. Our research team is
predominantly of Black African or Caribbean descent and fits within our study
population. As Black researchers, we have an inherent, personal understanding of the

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subject matter and may have shared lived experiences as some of the study participants.
We used an anonymous electronic survey. This method was selected for multiple reasons;
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(1) anonymity of an electronic survey format may foster participants’ candid responses
regarding sensitive material describing racism; (2) Ontario is a large province and
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potential participants are likely geographically dispersed; and (3) a knowledge gap exists
regarding the population of Black physicians and physician trainees in Ontario. This
study was completed as part of a required family medicine residency research project
(J.M. first author) for the Department of Family and Community Medicine, at the
University of Toronto with overall study supervision (A.L.). Residency research project
objectives, protocols, and study tools are approved by a research team comprising of
individual project supervisor (A.L.), resident academic project coordinator, research
associate, and residency program director. Our survey was conducted between March 22
and April 13, 2018.
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Study population and recruitment
Eligibility requirements for study inclusion were physicians or physician trainees
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(residents/fellows) who self-identified as Black (African/Afro-Canadian/African-
American/Afro-Caribbean) and were practicing or currently in training in Ontario. We
recruited potential participants via the Black Physicians’ Association of Ontario (BPAO),
of which our research group includes members. The BPAO is a not-for-profit

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organization whose goals are to advance the representation of Black Ontarians in medical
education and reduce racialized health inequities.12 The BPAO operates a listserv for
regular communication with their membership of practicing Black Ontarian physicians
and physician trainees which allowed us the rare opportunity to conduct a provincial
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survey of Black physicians and trainees in Ontario. However, the BPAO listserv was
recognized as not representing all Ontarian Black physicians, so we adopted a snowball

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sampling method13,14 to maximize responses. Survey recipients were asked to forward the
email to potential participants who were not BPAO members and met the inclusion
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criteria to expand our reach. The survey was originally emailed to 121 Black physicians
who were identified from the BPAO listserv as practicing Ontarian physicians or
physician trainees. Consent was implied by participation in the survey. An initial email
announcing the survey was sent to the general BPAO listserv in the BPAO newsletter on
March 20, 2018. An email to the identified physicians/physician trainees in the BPAO
listserv was sent on March 22, 2018, introducing the survey and including the electronic
link for participation. The survey was closed on April 13, 2018, with 2 reminder emails
sent prior to this date (total survey window of 3 weeks).
Survey
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The survey consisted of 4 sections: (1) Demographics; (2) Experiences of
racism/discrimination; (3) Career influences; and (4) Mentorship. The different sections
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helped guide the designation of themes for analysis. An initial list of questions was
chosen based on previous qualitative studies that investigated African American
residents’15 and physicians’16 experiences in medicine. We edited this list for conciseness
and formatted the remaining questions for suitability to an online survey format (J.M. and
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A.L.). To further incorporate topics that we anticipated may not be captured in some
open-ended questions, we formatted some probing topics used in interviews15 as
standalone questions for the online survey. For example, a probing topic for discussion
on the experience and impact of mentorship15 was adapted to: “How important is
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mentorship to you”’ and “During your training, did you feel like you had adequate access
to mentorship?” Rating scales were used to facilitate ease of completion and data
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analysis. For resident projects, a PhD-trained research associate and resident academic
project coordinator reviewed research protocols. For our project, the survey went through
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multiple rounds of review to edit questions for clarity and relevance (see List 1).
Analytic methods
First author (J.M.) conducted an initial descriptive analysis of closed-ended survey
responses with subsequent independent review by author A.L. Confidence intervals were
determined using The Survey System software (Creative Research Systems, Sebastopol,
California). For qualitative data (open-ended responses), we performed a thematic
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analysis. Two authors (J.M., A.L.) independently reviewed and coded individual
responses, and thereafter derived themes which corresponded to the survey sections.
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Themes were reviewed to ensure accurate representation of responses. There was
agreement between raters (J.M. and A.L.) with regards to derived themes.
Ethical approval
Research ethics approval was obtained through the St. Michael’s Hospital Research
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Ethics Board.
Results
There were a total of 46 respondents (response rate cannot be accurately calculated due to
the snowball sampling method utilized, but it is no greater than 38% considering the 121
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initial recipients).
The majority of respondents (63%) were female (see Table 1). Most (63%) respondents
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were practicing physicians at various career stages, with the remainder residents (30%)
and fellows (6.5%). Participants were predominantly in training (37%) or 10 years or less
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from their training (39.1%). The majority of participants completed their training in
Canada (63%) with slightly less than one-third having completed their training in the
USA/Caribbean (26.1%) and Europe (4.4%).
Both close-ended responses (see Table 2) and themes from open-ended responses were
categorized as: (1) Influence of race on career choices; (2) Negative experiences; (3)
Dealing with negative experiences/inaction; (4) Positive experiences; or (5) Mentorship.
Influence of race on career choices
Race played multiple roles in career decisions for many participants, most commonly in
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practice location (53.5%) but for some, in specialty choice. Respondents noted the intent
to practice in urban and suburban centers, where visible minority status would be more
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common than in rural areas. Those reporting influence in specialty choice cited a variety
of reasons including influence/presence of Black mentors in their chosen specialty, as
well as increasing representation. Others stated their motivation towards improving the
health of Black Canadians: “I feel that as a future family physician, I will have the option
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of focusing or tailoring my practice toward advancing the health of Black Canadians.”
(P09)
Negative experiences
More than 70% of respondents reported negative experiences based on their race. Some
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responses were centered on differential treatment and differing expectations (either
higher or lower) for Black trainees/physicians as compared to their counterparts with one
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respondent remarking: “As a medical student, myself and other Black students were told
we had to work harder to appear as competent as our white colleagues.” (P45)

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Participants described various forms of perceived racism/discrimination/stereotyping,
such as being regularly mistaken for floor aides, housekeeping, personal support
workers, or nurses, and colleagues making stereotypical assumptions about respondents,
or making offensive remarks about their looks and hair. Participants expressed various
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experiences of being “othered”—e.g., being repeatedly asked where they were from even
when they were born in Canada. A few respondents wrote that they felt as though their
competence was occasionally called into question with patients not acceding with their
plan until a White physician agreed with it: “I also had an experience where a family did
not follow through on a treatment plan until a White, tall MD with a British accent agreed
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with the plan I had outlined.” (P10)
Most respondents reported rare instances of discrimination from peers or superiors, but
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some described feeling excluded (“Often it’s about being excluded from the ‘old boys
club’ as opposed to blatant overt discrimination” [P14]), expressed lack of support, lack
of mentorship, minimal support for preparation for promotion, less access to
opportunities and lack of recognition for the work that they did as compared to their
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peers. One respondent remarked: “I felt very isolated. I performed at a high level and did
not get recognition.” (P11)
More overt discrimination was reported to come from patients. A few survey respondents
recall patients walking out of a room, or asking for a “lighter doctor,” with one recalling a
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patient protesting “I don’t want that nigger taking care of my kid.” (P26)
Participants reported a lack of action when experiencing prejudice or racism in the

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presence of their White peers or supervisors. After a patient said something racist in front
of one respondent and their preceptor, the respondent wrote: “My White preceptor
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apologized to me after but didn’t say a word to [the patient]. I will never forget the way I
felt having to be in that room.” (P14)
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Dealing with negative experiences/inaction
All but 2 participants reported not receiving any training on how to deal with negative
experiences of racism/discrimination. Participants reported mostly internalizing negative
experiences, “just dealing” and moving on: “[I] mostly ignore and move on.” (P09) Some
declined reporting for fear of repercussions, but as respondents gained seniority, some
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felt more empowered: “The way I faced each situation evolved throughout my training
and career … as I went further, I continued to learn how to speak for myself and confront
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the situation directly.” (P21)
Support in dealing with negative experiences was mostly sought from outside of the
medical community—from family and friends. If support was sought at work, it was
mostly from other Black colleagues: “If there is another black person at work (usually not
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an MD), [I would] vent to them in private. I certainly don’t feel that I can safely share
these experiences with most of my non-Black colleagues.” (P14) Few respondents sought
support from their superiors and did so with varying reception. While some felt
supported, others had their experiences dismissed: “I was told that I should be careful
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about levying accusations of racism as they would stick with someone forever.” (P01)
When asked how these negative experiences could be improved, a common response
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amongst participants was by raising awareness: “It needs to be talked about. We are
having conversations about gender inequality. We need to have [them] about race.” (P37)
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Some participants also stressed the importance of better record-keeping and data to track
equity statistics: “Subtle, more insidious forms of racism persist (e.g., being passed over
for promotions or senior positions). This leads me to believe that more work must be
done to ensure equity in medicine. For example, keeping statistics on minority hiring and
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advancement within the faculty of medicine. Only then can these more subtle forms of
racism be examined to better the experiences of Black-identifying physicians.” (P28)
Respondents commented on the importance of increasing mentorship and fostering a
better sense of community with Black physicians locally and internationally, highlighting
the value of creating safe and confidential spaces to discuss concerns unique to Black
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physicians without fear of retaliation. Respondents wrote of increasing/facilitating
educational workshops on discrimination and bias, not only centered on the experiences
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of marginalized patients but of visible minority physicians as well. Given the under-
representation of Blacks in medicine, leveraging relationships with other visible minority
allies was considered a key success factor.
Positive experiences
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Respondents reported positive experiences of collegiality with other Black allied health
professionals. Respondents noted a tangible sense of encouragement and support from
other Black (non-physician) health staff that would express how pleased they were to see
a Black physician, noting it as a rare thing. Positive experiences were also reported in the
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form of physician-patient interactions with one physician remarking: “Patients sometimes
comment that they trust me more because I’m one of them. I’d say every single day that I
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work, a Black patient will tell me they’re proud of me.” (P36) One participant reported
that Black families would request to join her medical practice so that their children could
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have a visible role model. (P41) One statement summarized the sentiment amongst many
respondents: “I connect with black patients and staff differently. I don't think it's
demonstrably better than my connection/relationships with people of other backgrounds,
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but there is certainly a tangible familiarity that is not present in other professional
interactions.” (P28)
Mentorship
Mentorship was important to all participants. However, approximately half of
respondents reported not having enough access to mentorship in their training. One
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physician noted: “I found that I have needed to be my own advocate and be more
proactive about finding opportunities for mentorship. Of course, this is fraught with
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difficulty when you don’t even know what the opportunities are that you should be
looking for.” (P21) Many participants were currently, or had previously been mentors,
and all expressed the influence of their racial background on their decision to mentor. All
identified the importance of having a mentor of similar ethno-racial background: “I think

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it’s extremely important as I would more openly be able to share my experiences and get
some advice from someone who has been in a similar situation.” (P27) Respondents
reported that mentorship of Black-identifying trainees, specifically by other Black faculty
mentors, was important in improving the experiences of the trainees, who would benefit
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from role models that looked like them. Respondents commented on the importance of
cultural sensitivity/competency of mentors of a different race but with other shared

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backgrounds:
I think the most important factors in mentorship are willingness to

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understand and listen with intention. People who share a given
background (whether gender, race, language, age, etc.) automatically have
a lot in common due to some degree of shared experience; there is less to
explain or “try to understand.” That being said, I don't think it's impossible
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for mentors or those who should teach to gain enough understanding to be
able to fill those roles effectively. (P22)
Discussion
The key finding of this paper is that racism has a significant impact on Black physician
and trainee experiences in Canada. To our knowledge, this is the first study to explore
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Black Canadian physician experiences of discrimination. Respondents described micro-
aggressions and stereotyping from patients, peers and preceptors; feelings of exclusion;
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and fewer opportunities for support, mentorship, advancement and promotion. They also
described building community among Black health professionals and allies in order to
find support, and moments of pride experienced with Black patients who saw a Black
physician for the first time, shattering the stereotypes. Our study findings are directly in
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line with the concept of institutionalized racism.
Camara Phyllis Jones defines institutionalized racism as the structures, policies, practices,
and norms resulting in differential access to the goods, services, and opportunities of
society by race.17 The United Nations recently flagged institutional racism as a pervasive
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problem in Canada;1 our study suggests that the field of medicine is no exception. A
significant barrier to addressing this in the Canadian context has been a pervasive belief
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that racism is not a significant issue in Canada.2 Although Canada has had a long history
of anti-oppression advocacy, it did not have a paradigm shifting Black civil rights
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movement; it is not the “birthplace” of critical race theory,8 nor does it have an
organization such as the National Medical Association18 to advocate for Black physicians
and patients. The tide is, however, shifting—regional and national networks of Black
Canadian medical students, residents, and physicians are now emerging and advocating
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for change within Canadian medical schools.12,19-21 There is now a greater focus on social
accountability in medicine and focus on diversity in medical education in Canada.22-24
Since 2015, many needed changes have occurred to address systemic racism within
Canada: the acknowledgement of anti-Black racism by the government of Canada,25 the
publication of the Truth & Reconciliation Commission report acknowledging the impacts
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of colonialism, residential schools, and anti-Indigenous racism in Canada,26 the
implementation of a Canadian Anti-racism Strategy,27 and the establishment of the Anti-
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racism Directorate in Ontario.28
Relationship to the literature
Studies from other countries report findings that are echoed in our study. Liebschutz et al
reported themes of discrimination, differing expectations and social isolation amongst

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African-American residents. These negative experiences were contrasted with
connections with Black physicians, staff and patients. Similar to our study, residents
strongly advocated for Black mentors and spoke of creating more supportive
environments and raising awareness of issues as means to improve their training

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experiences.15
Similar issues and solutions have been identified by Black and Minority Ethnic (BME)
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physicians and trainees in Europe. In the British Medical Journal’s special issue on
racism in medicine, it was noted that racism was prevalent in British medical schools.29
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In an informal social media survey, BME physicians were asked about the problems they
faced, and common issues included: micro-aggressions (e.g., being asked “where are you
really from?”); being ignored, marginalized, or having their contributions minimized; and
disparities in promotion and pay. Potential solutions included “the crucial need for
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mentorship, coaching, encouragement, and support from peers and seniors, whether BME
or white British.”30
Limitations
Our study has limitations. First, the response rate and representativeness of our sample
responses are unknown. Second, due to the small sample size, we were unable to perform
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subgroup analyses. Slightly less than a third of study participants completed their training
outside of Canada and may have reported experiences that occurred outside of Ontario.
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Third, participants were at differing career stages and some were reporting experiences
from many years in the past. Finally, as this was a resident research project, we were
limited to a short study time period that limited our data collection window and did not
allow for piloting of survey questions.

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Implication of research for medical educators
Future research regarding racism experienced by Black Canadian physicians and trainees
can build upon our findings to answer questions more systematically across all of
Canada’s provinces and territories regarding the prevalence and nature of discriminatory
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events. Ideally, an in-depth CRT framework for analysis such as the one proposed by
Milner et al31 which involves “researching the self, researching the self in relation to
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others, engaged reflection and representation, and shifting from the self to system” would
provide greater rigour. Canada and the United States have unique historical contexts
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regarding racism, discrimination, and medical education and are undeniably traversing
differing paths to justice. Our group believes comparative medical education research
across differing contexts (including future contributions from other countries’ medical
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educators) holds the potential to inform and advance a global path to justice and health
for all.
Conclusions
This study disrupts the silence on institutional racism in Canadian health care and in
medical education, and we consider it to be a starting point for fulsome future research.
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One can no longer assert that racial discrimination within Canada’s health care and
medical education contexts is a rare event to be managed one incident at a time.
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Acknowledgement, advocacy and action combating racial discrimination are necessary
for Canadian medical education and health care going forward. By amplifying the voices
from the margins, we hope that this work will be a catalyst for positive change in medical
education, within and beyond Canada.

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student-association. Published February 22, 2017. Accessed April 29, 2020.
22. Young ME, Razack S, Hanson MD, Slade S, Varpio L, Dore KL, and McKnight
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D. Calling for a broader conceptualization of diversity: Surface and deep diversity
in four Canadian medical schools. Academic Medicine. 2012;87(11):1501-1510.
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23. Young ME, Thomas A, Varpio L, et al. Facilitating admissions of diverse
students: A six-point, evidence-informed framework for pipeline and program
development. Perspectives on Medical Education. 2017;6(2):82-90.
doi:10.1007/s40037-017-0341-5.
24. Moineau G. Our social accountability: when will we walk the talk? Medical
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Education. 2014;49(1):9-11. doi:10.1111/medu.12629.
25. Time to recognize anti-black racism, unconscious bias does exist in Canada:
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Trudeau. The Globe and Mail.
https://www.theglobeandmail.com/news/politics/time-to-recognize-anti-black-
racism-unconscious-bias-does-exist-in-canada-trudeau/article37957855/.
Published February 13, 2018. Accessed April 29, 2020.

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26. National Centre for Truth and Reconciliation. Reports. http://nctr.ca/reports.php.
Accessed April 25, 2020.
27. Building a Foundation for Change: Canada’s Anti-Racism Strategy 2019–2022.
https://www.canada.ca/en/canadian-heritage/campaigns/anti-racism-
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engagement/anti-racism-strategy.html. Published July 17, 2019. Accessed April
29, 2020.
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https://www.ontario.ca/page/anti-racism-directorate. Published July 4, 2016.

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29. Linton S. Taking the difference out of attainment. British Medical Journal.
2020;368:m438. doi:10.1136/bmj.m438.
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30. Oliver D. Racism in medicine—what ethnic minority doctors told me on
Twitter. British Medical Journal. 2020;368:m484. doi:10.1136/bmj.m484.
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400. doi:10.3102/0013189x07309471.
D
TE
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C
C
A
23
Table 1
Demographics of 46 Survey Respondents
Characteristic % (no.)
Gender
Male 37 (17)
Female 63 (29)
Age
0 - 30 17.4 (8)
31 - 40 52.1 (24)
D
41 - 50 21.7 (10)
51 - 60 6.5 (3)
> 60 2.2 (1)
Current level of training
TE
Resident 30.4 (14)
Fellow/Post-graduate 6.5 (3)
Practicing physician 63.0 (29)
Years in practice
In training 37.0 (17)
<1 4.3 (2)
1-5 15.2 (7)
EP
5 - 10 19.6 (9)
> 10 23.9 (11)
Location of training
Canada 63.0 (29)
U.S./Caribbean 26.1 (12)
Europe 4.4 (2)
Other 6.5 (3)
C
Current practice setting

Urban 80.4 (37)
Suburban 10.9 (5)
Rural 0 (0)
C
Mixed 8.7 (4)

A
24
Table 2
Survey Results
Theme Responses Na Responses % [95% CI]

Career Influences
Impact of race on picking No 34/43 79.0 [66.8, 91.2]
career/specialty
Influence on current setting of Definitely/Probably 23/43 53.5 [38.6, 68.4]
practice yes
Might or might not 8/43 18.6 [7.0, 30.2]
D
Probably/Definitely 12/43 27.9 [14.5, 41.3]
not
Negative experiences
Differential treatment because of Yes 29/41 70.7 [56.8, 84.7]
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racial background
Negative experiences because of Yes 29/41 70.7 [56.8, 84.7]
racial background
Discrimination from superiors Rare/Very rare 26/39 66.7 [51.9, 81.5]
Occasional 10/39 25.6 [11.9, 39.3]
Frequent/Very 3/39 7.7 [-0.7, 16.0]
frequent
EP
Discrimination from peers/colleagues Rare/Very rare 29/39 74.4 [60.7, 88.1]
Occasional 6/39 15.4 [4.1, 26.7]

Frequent/Very 4/39 10.3 [0.7, 19.8]
frequent
Discrimination from students/juniors Rare/Very rare 33/39 84.6 [77.3, 95.9]
C
Occasional 6/39 15.4 [4.1, 26.7]

Frequent/Very 0/39 0.0
frequent
Dealing with negative experiences: No 37/39 94.9 [88.0, 101.8]
C
Training on how to deal with

incidents of discrimination or racism
Positive experiences Yes 26/41 63.4 [48.7, 78.2]
Mentorship
A
Importance of Mentorship Very/Extremely 36/39 92.3 [83.9, 100.7]

important
Moderately important 3/39 7.7 [-0.7, 16.1]
Slightly/Not important 0/39 0.0
Adequate access to mentorship No 20/39 51.3 [35.6, 67.0]

during training
Very/Extremely 23/39 60.0 [43.5, 74.4]
25
Importance of mentor with similar important
ethno-racial background as yourself?
Moderately important 10/39 25.6 [11.9, 39.3]
Slightly/Not important 6/39 15.4 [4.1, 26.7]
Not at all 0/39 0.0

Current or past involvement in Yes 29/39 74.4 [60.6, 88.0]
mentorship as a mentor
Influence of status as a visible Very/Extremely 26/29 89.7 [78.6, 100.7]
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minority in your decision to mentor influential
Moderately influential 3/29 10.3 [-0.7, 21.4]
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Slightly/Not 0/29 0.0
influential
Abbreviations: CI, confidence interval.
a
Responses were expressed as percentage and fraction of total respondents to the particular question, N. As not all
participants responded to each question, the total number of the respondents to each question varies.
EP
C
C
A
26
List 1
Survey Questions
 How, if at all, do you feel that your status as a minority has influenced your decision with
regards to picking your specialty?
 Do you feel that your status as a visible minority has influenced your current setting of
practice (urban/rural)? If currently still in training, do you feel like your status as a visible
minority is likely to influence your future setting of practice?
 Have you been treated differently during your medical training/career because of your
D
racial background?
 Have you had any positive experiences during your medical training because of your
racial background?
 Have you had any negative experiences during your medical training because of your
racial background?
TE
 Have you experienced any discrimination from:
o Your Superiors?
o Your Peers/Colleagues?
o Students/Juniors?
 How did you deal with these negative experiences?
 Did you feel as though there was an opportunity/space/environment created where you
could openly discuss/debrief a negative situation were it to occur?
EP
 Did you ever receive any particular training as to how to deal with incidents regarding
discrimination or racism?
 How important is mentorship to you?
 During your training, did you feel like you had adequate access to mentorship?
 How important would it be for a mentor to have a similar ethno-racial background as
yourself?
 Are you currently involved in mentorship as a mentor?

C
How influential was your status as a visible minority in your decision to mentor?
 Do you have any suggestions for improving the experiences of black-identifying
physicians/physician trainees in medicine?
C
A
27

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Journal of the Association of American Medical Colleges

Uncomposed, edited manuscript published online ahead of print.

Patients, Pride, and Prejudice: Exploring Black Ontarian Physicians’ Experiences

of Racism and Discrimination

A. Lofters is family physician, associate professor, and clinician scientist, Department of

Medicine, University of Toronto, and president of the Black Physicians’ Association of

Ontario, Toronto, Ontario, Canada.

professor, Department of Psychiatry, Faculty of Medicine, University of Toronto,

Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-0820-4521.

St., Toronto, ON, Canada, M4Y 1P2; email: j.mpalirwa@mail.utoronto.ca.

Funding/Support: None reported.

Hospital Research Ethics Board.

Previous presentations: Research findings were presented as a poster at Learn Serve

Canada, reflecting a knowledge gap needing correction to combat racism in Canadian

experienced by participant Ontarian physicians in order to challenge the purported rarity

An anonymous online survey of physicians and trainees who self-identify as Black

(African/Afro-Canadian/African-American/Afro-Caribbean) was administered in March

eligible colleagues (non-BPAO members) to maximize responses. Survey data was

analyzed and key themes described.

Black patients. Negative discrimination experiences included differential treatment and

mentors with similar ethno-racial backgrounds.

systematic collection of information regarding Black physicians’ and trainees’

medical education system is situated. This undoubtedly generates nation-specific medical

education priorities, including education research priorities. Acknowledgment of racism

racism as opposed to a true rarity of racism in Canadian health care education.4

discourse on racism, medical educators such as Karani et al have challenged educators,

educational contexts and commit to its undoing.7 In particular, Karani et al recommend

experiences of racism in health professions education.7 Critical race theory “ … values

experiential knowledge as a way to inform thinking and research” because narrative

a CRT-aligned approach, we surveyed Black physicians and postgraduate medical

Canadians enrolled in Canadian health professions education.

practicing physicians in Ontario.11 The population of Black physician trainees is

Ontario regarding health care-related experiences of racism. Our research team is

population. As Black researchers, we have an inherent, personal understanding of the

individual project supervisor (A.L.), resident academic project coordinator, research

and April 13, 2018.

Eligibility requirements for study inclusion were physicians or physician trainees

American/Afro-Caribbean) and were practicing or currently in training in Ontario. We

of which our research group includes members. The BPAO is a not-for-profit

regular communication with their membership of practicing Black Ontarian physicians

recognized as not representing all Ontarian Black physicians, so we adopted a snowball

sent prior to this date (total survey window of 3 weeks).

chosen based on previous qualitative studies that investigated African American

open-ended questions, we formatted some probing topics used in interviews15 as

First author (J.M.) conducted an initial descriptive analysis of closed-ended survey

California). For qualitative data (open-ended responses), we performed a thematic

USA/Caribbean (26.1%) and Europe (4.4%).

Dealing with negative experiences/inaction; (4) Positive experiences; or (5) Mentorship.

Influence of race on career choices

of reasons including influence/presence of Black mentors in their chosen specialty, as

responses were centered on differential treatment and differing expectations (either

we had to work harder to appear as competent as our white colleagues.” (P45)

Participants described various forms of perceived racism/discrimination/stereotyping,

workers, or nurses, and colleagues making stereotypical assumptions about respondents,

of mentorship, minimal support for preparation for promotion, less access to

not get recognition.” (P11)

Participants reported a lack of action when experiencing prejudice or racism in the

felt having to be in that room.” (P14)

experiences of racism/discrimination. Participants reported mostly internalizing negative

racism be examined to better the experiences of Black-identifying physicians.” (P28)

Respondents commented on the importance of increasing mentorship and fostering a

representation of Blacks in medicine, leveraging relationships with other visible minority

allies was considered a key success factor.