Assessing the need for Black mentorship within residency training in Canada

What factors affect the experiences of Black medical learners in Canada?

Multiple factors contribute to the experiences of Black learners in medicine. Internalized and systemic racism may lower self-efficacy and confidence during the application to medical school.1 External barriers include a lack of mentors, finances and noninclusive admissions processes.1 Black medical learners experience a diminished sense of belonging, differing expectations and feeling othered, resulting in a lack of retention in their programs.2 A disproportionately higher rate of attrition during residency has been documented.3 In the United States, about 20% of residents dismissed from their programs in 2015 were Black, despite Black residents making up only 5% of the resident population.4

Data from the University of Toronto showed that in 2020, 56% of Black medical students, 66% of Black residents and 39% of Black fellows experienced discrimination at least once within the past year.5 This is likely rooted in anti-Black racism and institutional policies and practices that promote biased admission processes, microaggressions, discrimination and differential treatment from supervisors, peers and patients.2^,6^,7 A cross-sectional survey among general surgery residents in Canada found that residents who were visible minorities reported being perceived as less competent owing to their race, compared with nonvisible minorities.8 Black trainees may also experience emotional abuse, gaslighting and unfavourable evaluations.9 These barriers persist into independent practice and affect career progression, compensation and stressors faced by Black physicians as documented in a literature review from the United Kingdom.10

The barriers and experiences outlined previously ultimately result in the underrepresentation of people identifying as Black within medicine. In Ontario, Black physicians make up about 2.3% of practising physicians in the province, compared with 4.7% of the Black population.11 Although limited race-based data collected by medical schools in Canada are available, a recent survey across English-speaking medical schools estimated the proportion of Black medical students to be 1.7% compared with 6.4% of the Black population in Canada.12 To our knowledge, few Canadian residency programs collect race-based data, therefore, the extent of underrepresentation in this group is unknown.

In recent years, targeted efforts in the admission process for Black learners have been instituted to improve representation. For example, the implementation of the Black Student Application Program at the University of Toronto has resulted in 75 Black students gaining admission over 4 cycles since 2018, compared with 1 student who was admitted in 2016.5 Similar programs are being adopted by other Canadian medical schools, including the University of British Columbia, University of Calgary, University of Alberta, University of Ottawa, Queen’s University, McMaster University, McGill University and Dalhousie University. With an increasing number of Black medical trainees, mentorship will be crucial to their professional development and career advancement.7^,13

Can mentorship improve representation and experiences of Black medical learners?

Across North America and in the UK, access to culturally appropriate and relevant mentorship has been shown to improve retention and promotion, as well as alleviate stressors that may hinder the academic success of learners and junior faculty.14^–16 A 2021 systematic review that evaluated mentorship programs for underrepresented physicians and trainees in academic medicine highlighted numerous benefits of mentorship for this group. These included an increase in successful applications to competitive and historically underrepresented residency programs, publications, grant awards and academic promotions, as well as improvement in self-confidence, leadership, teaching and clinical skills to care for underserved populations.17 Similarly, culturally concordant mentorship has been shown to improve recruitment and retention among Black educators.18

In Canada, mentorship provided through the Community of Support (CoS) program has improved representation. The CoS is a nationwide program, organized through the medical schools, that supports prospective students who identify as Black, Indigenous, Filipino, socioeconomically disadvantaged or having a disability when applying for health professions such as medicine. They run different courses including Medical College Admission Test (MCAT) preparation, biostatistics and research support. They also hold an annual conference (Ignite) so that prospective students can network with medical students and physicians.19^,20 A total of 130 students from CoS were accepted to a medical school in Ontario in 2021 compared with 3 in 2016.

In addition, programs implemented for Indigenous students in Canada show the benefits of mentorship, especially those that meet the Indigenous culture in its approach, content and assumptions. These programs have been shown to increase students’ self-confidence and sense of belonging.15^,16^,21 An example is the Indigenous mentorship model based on Flanagan’s Critical Incidents Technique that, unlike traditional mentorship, focuses on Indigenous identity, ethics, culture, advocacy and teaching others about racism. Mentors within this model help mentees to navigate the institutions while deconstructing colonial mindset.15^,16 This highlights the importance of culturally concordant mentorship.

Do Black medical learners in Canada have adequate mentorship?

Mentorship programs for Black high school, undergraduate and medical students have increased in number over the past few years;20^,22^–26 however, this is not replicated for Black residents, fellows or early-career physicians, especially in regard to racially concordant mentorship. Nonracially concordant mentorship programs have been available for Black residents; however, studies have shown that racialized mentees can experience a disconnect in sociocultural and behavioural understanding from nonracialized mentors.10^,15 The mentoring relationship in racially discordant pairs can be negatively affected by unconscious bias.27 Cultural mistrust and a reluctance to discuss race may make it difficult to have a bidirectional mentoring relationship.27 In view of this, a call for cultural concordance in mentorship between Black physicians and trainees in Canada has been made.6

Black Physicians of Canada (BPC) is a national medical organization established in 2020 to respond to the unique needs of Black physicians, trainees and the Black community. We conducted a needs assessment survey between June 8, 2020, and July 22, 2020, in collaboration with the Black Physicians’ Association of Ontario and Black Resident Physicians of Ontario (Appendix 1, available at https://www.cmaj.ca/lookup/doi/10.1503/cmaj.212124/tab-related-content). The aim of the survey was to assess whether Black residents in Canada have adequate mentorship, asking questions about access to mentorship, interest in formal mentorship that would see Black residents matched with Black practising or retired physicians, access to mentors and preferences for mentorship. Twenty-seven Black residents across 8 Canadian universities and 10 specialties completed the survey. Three out of 4 (77.4%) participants did not have formal mentorship. All participants expressed interest in a Black-led mentorship program and wanted guidance on topics such as overcoming racial and gender barriers in medicine (Figure 1). Participants preferred mentors from a similar specialty, gender and race.

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Figure 1:

Interest in areas of mentorship.

How can racially concordant mentorship for Black residents be implemented in Canada?

A major challenge with establishing a racially concordant mentorship program for Black residents is the disproportionate number of learners compared with potential mentors. With a growing network of Black physicians across Canada, BPC serves as an ideal platform to address the needs identified by Black residents in our recent survey.

In 2021, BPC implemented a nationwide mentorship program to connect Black residents and early career physicians with Black physician mentors. Pairs were further matched based on gender and specialty, where possible, with an aim of strengthening the mentor–mentee relationship based on shared lived experiences. Mentors were expected to provide support related to navigating medical training while Black, as well as other mentorship priorities identified in the needs assessment survey, including research, financial management, work–life balance, career development, community activism and patient advocacy. Workshops to address unique challenges, such as microaggressions, were offered. Workshops were also offered to train mentors including peer-to-peer support in which mentors shared their mentorship experiences and expertise with each other, as well as a keynote speaker who provided modules on establishing and maintaining effective mentoring relationships. A total of 63 mentees across Canada were matched in its inaugural year. Most mentees were in postgraduate year (PGY) 1 (50%), followed by early career physicians within the first 5 years of practice (12.9%), and almost equal distributions of PGY2s (8.1%), PGY3s (11.3%) and PGY4s (9.7%). PGY5s represented 4.8% of the mentee population. About 67% of the mentees were located in Ontario, with 13% in Alberta and less than 10% in Quebec, BC, Nova Scotia and Manitoba.

Future plans involve expanding the reach of the program and evaluating its impact. Preliminary feedback from both mentees and mentors has been positive because of the opportunity to network and share lived experiences.

Despite success with implementing the BPC mentorship program, ongoing challenges remain in providing racially concordant mentorship for Black residents in Canada. First, the increasing number of incoming medical students and residents will place a further demand on Black physician mentors, contributing to the “minority tax” and burnout, hence, reducing the mental and emotional bandwidth to be able to remain in mentorship roles.28 This is further compounded by the limited funding available to implement and sustain programming. Strategies to increase and maintain the number of Black physician mentors are required to meet the increasing needs of Black learners.

Long-term strategies to increase available Black physician mentors may include focused efforts to hire more Black faculty to provide mentorship in academic settings and support to ensure that current learners complete their training successfully. Black Physicians of Canada has been collaborating with Canadian medical regulatory colleges to create safer learning environments for Black trainees as a strategy to retain trainees.29^,30 More immediate solutions could involve using allies and implementing training in structural racism and implicit bias for non-Black mentors interested in mentoring Black residents. Reverse mentorship, a process in which students mentor their senior faculty on the experience and perspectives of underrepresented minorities who are completing their medical degrees, has also been used to address staff perception of the experiences of underrepresented medical students.31 This type of mentorship has been shown to improve awareness of the negative experiences of racialized medical students, potentially leading to a more favourable racially discordant mentorship experience.31 Although individual-and interpersonal-level interventions, such as implicit bias training, are necessary to address these issues, racism within an institution can only truly be dismantled through structural changes, which requires systematic evaluation of the problem coupled with antiracism policies, ongoing monitoring and re-evaluation.32

Second, mentorship relations can be complex and it is important to match pairs based on multiple traits beyond race (e.g., socioeconomic status).33 This underscores the importance of connecting mentees and mentors with similarities based on multiple characteristics but does not downplay the importance of race, which is a large factor that drives experiences of Black learners in medicine.

Finally, the comprehensive needs of a mentee may be beyond what can reasonably be expected of an individual mentor. Thus, objectives should be established by the mentorship program, then further refined by the mentor and mentee, to ensure that expectations are managed. This may encourage the mentee to focus on the unique aspect of their mentorship pair (e.g., mentorship from a racially concordant mentor), and will not discourage them from seeking concurrent mentorship elsewhere to address additional needs.

Conclusion

Mentorship has been shown to promote professional development and career advancement. Furthermore, racially concordant mentorship can support Black learners in navigating challenges they face during their careers owing to systemic anti-Black racism. Yet, access to mentorship is a barrier in itself for Black learners. Black Physicians of Canada identified a lack of racially concordant mentorship for Black residents across Canada and subsequently implemented a nationwide mentorship program for Black residents, fellows and early-career physicians. With an increasing number of Black trainees entering medicine, focused efforts must be introduced to ensure they receive adequate mentorship. These formal programs are necessary to provide Black learners who have been historically marginalized with the tools and skills to succeed.