Unpacking the Social Constructs of Discrimination, Othering, and Belonging in Medical Schools

Abstract

Issue

Triggered by the lived experiences of the authors–one junior career, female, and black; the other senior career, male, and black–we provide a critical, sociological overview of the plight of racial/ethnic minority students in medical education. We analyze the concepts of categorization, othering, and belonging in medical education, which we use to shed light on the psychological and academic consequences of overgeneralizing social categories.

Evidence

The ability to categorize people into different social groups is a natural, subconscious phenomenon. Creating social groups is believed to aid people in navigating the world. This permits people to relate to others based on assumed opinions and actions. Race and gender are two primary dimensions of categorization, with race or ethnicity being a particularly salient category. However, over-generalization of social categories can lead the categorizer to think, judge, and treat themselves and members of a perceived group similarly, leading to prejudice and stereotyping. Social categorization also occurs in educational settings across the globe. The consequences of categorization may influence a student’s feelings of belonging and academic success.

Implications

Our analysis reflects on how to promote equitable opportunities for ethnic minority medical trainees through the lens of those who have experienced and succeeded in an inequitable system. By revisiting the social and psychological constructs that determine and influence the academic progress and success of minority students in medical education, we discovered that more engagement is (still) needed for critical discourse on this topic. We expect such conversations to help generate new insights to improve inclusion and equity in our educational systems.

Keywords:

• Categorization
• discrimination
• othering
• belonging
• education

Introduction

With the ongoing surge in global migration, more people from different ethnic and cultural backgrounds co-exist within single communities. With the diversity in language, skin color, and ethnicity/race of these people, different categorizations have emerged in those communities with significant implications, i.e., discrimination, prejudice, and stereotyping of individuals and groups of people.¹ Creating categories is believed to aid people in navigating the social world, as it helps people organize an array of knowledge about human attributes.² Although the process of social categorization can be anticipated, these categories and their meanings are social constructions.³

There are two approaches that people often use to categorize, namely (1) categorizations emphasizing shared traits and (2) those that minimize differences.⁴ Globally, demographic features such as gender, age, ethnicity, personality interests, and income or occupation are often used to categorize people into different groups.⁵ However, unlike distinct categories such as gender and age, race or ethnicity is particularly salient.⁶ For example, race as a category is widely (and incorrectly) used as a collective categorization of different groups of people who possess particular physical attributes, such as skin color, hair texture, or apertures of the eyelids.⁷ This often leads to ethnic minority and majority group categorizations based on physical appearances. It is also a consequence of the observed diversity resulting from increased migration and involuntary displacement of people globally. Currently, there is no internationally agreed definition of “ethnic minority” (EM) in the literature.⁸ However, in this paper, we describe EM groups as socially constructed categories of people with a different racial, ethnic, or national background from the dominant majority within a particular society at a particular time.⁹

EM individuals are likely to experience negative consequences of categorization, such as discrimination and racism, which can have harmful effects on their feelings of belonging and professional success.^10–12 For example, in a predominately white society, dark skin can be identified as characteristic of an EM group and regularly and incorrectly used as a marker to attribute certain disorders, crime, and violence, causing the stigmatization of an entire category of people.¹³ Subsequently, such categorizations tend to stick and are sustained because any information that validates stereotypes is easier to remember than information that refutes them.^14,15 Furthermore, people who are perceived by others or themselves as distinct, racially, culturally, and ethnically risk falling victim to the consequences of differentiation and stereotyping associated with categorization, i.e., discrimination, isolation, lack of belonging, and loneliness. Unsurprisingly, social categorization is not limited to single institutions but occurs in all sectors of society, including educational institutions such as universities and schools.

EM students are frequently discriminated against based on their race and ethnicity (or difference). There is reason to believe that the presence of discrimination and absence of belonging in an educational setting significantly predicts academic outcome, motivation, and effort in education. ^16–18 Racial or ethnic discrimination is a serious global issue that affects EM students including medical students, despite the need for diverse medical professionals to meet the need of a increasingly diverse communities.^19–22 It is imperative to understand the process and consequences of categorization and the role social constructed factors like othering and belonging plays on EM students’ academic outcome and wellbeing.

The factual case described below is of a former medical student and researcher named Jane (not her real name) and is used to showcase what and how various students experience othering and categorization in medical education.

The case of Dr. Jane

Dr. Jane is a black African woman conducting a qualitative thesis project on a topic that reflects her educational experience as an African in Europe. While conducting interviews, she observed that she shared similarities with her participants who reported moving from their home countries to study in Europe and “suddenly” becoming categorized as EM students. They reported that this new category came with feelings of being othered, discriminated against, targeted by microaggressions, and excluded. Concurrently, they reported that they found belonging and were able to create a community among other EM students. These were all feelings that Dr. Jane knew all too well after experiencing racist remarks from teachers and students and feelings of exclusion during her study in Europe. All these experiences affected her sense of belonging and academic performance. However, like the participants in her survey, Dr. Jane built a community with other minority students, which improved her sense of well-being and performance, academically.

The narrative above describes the experiences of a newly labeled EM medical student who studied in a relatively conservative Eastern European country and noticed the same lived experiences among EM students in Western Europe. Similar findings were present in education literature where EM students reported racial categorization and its consequences, i.e., othering, discrimination, and isolation and which led to increased dropout rates, poor academic performance, and limited professional attainment.^23–25 Unfortunately, there is a dearth of information about how socially constructed concepts, like othering and belonging, affect the lives of EM students. Therefore, it is crucial to understand these concepts and, importantly, their effects on EM students to create inclusive spaces in medicine and help promote belonging. In so doing, opportunities can be created to help EMs attain their academic and professional goals. This analysis, therefore, explores the sociological and psychological perspectives of socially constructed concepts, i.e., othering and belonging, by authors with lived experiences of such phenomena. Our objective is to understand how EM medical students experience othering and discrimination and its impact on their feelings of belonging and academic performance. Through this exercise, we expect to create (more) awareness of othering and belonging in medical schools. Also, we aim to highlight the effects of these constructs on EM students and inform medical schools on the need for inclusive and diverse spaces for EM students to grow and thrive.

The social construct of othering evolving from categorizations

Creating categories through vocabulary to describe race or ethnicity does not seem harmful. However, overgeneralization of such categories can lead the categorizer to think, judge, and treat themselves and members of a perceived “dominant” group similarly, leading to outgroup homogeneity, prejudice, and self-stereotyping.^15,26 To be part of an “in-group” is a significant phenomenon of privilege in which individuals in that group build communities and security and possess the power to frame the “out-group” as an “other” and treat them unfairly.²⁷ Othering can simply be defined as the “simultaneous construction of the self or in-group, and the other or out-group in mutual and unequal opposition through identification of some desirable characteristics that the self (in-group) embodies, and that the other (out-group) lacks.²⁸ This discursive process of separating “We” from “Other” as a process of creating hierarchies of power implies that the “other” is not just (implicitly) inferior but radically alien.²⁷ As a result, an impenetrable boundary between “the self” and “other” is created that makes it easier to justify social exclusion and discrimination due to differences found between “them and us.”²⁷ Stereotypes subsequently emerge, and in our analysis, it is the process whereby generalizations about attributes or characteristics of a group of people are formed.²⁹ Stereotypes undermine people’s social standing by “othering” them to a specific attribute or disposition that leads to discrimination.³⁰ In this article, we refer to discrimination as the unequal treatment of persons or groups based on (their) race or ethnicity.³¹ This process of discriminating and othering can lead to alienation and perpetuation of group stereotypes, prejudice, and inequality.³² It creates the “us versus them” mindset, which is socially constructed and not only detrimental to society but also dangerous in academic (learning) settings.

For example, Europe defined “Orientalism” and its identity in an exoticized, reductionist, and alienating fashion.³³ Bhabha³⁴ affirmed that the use of the racial stereotype of “Orientals” to describe people of East Asian descent validated the institutionalized systems of racist imperial administration over the “inferiors” (Orientals).^34,35 The stereotype then became derogatory and aggressive discourses, creating divisions between the colonizers and colonized. The classroom could be considered a mirror of this type of social system where the hierarchical division of dominance leads to the exclusion and discrimination of a certain group of students, thereby constituting an ideal context for teachers and administrators to develop stereotypes and biases of EM students.^36,37

Research from educational settings indicates that tutors often assume that students from the “dominant” group share equal views as fellow students from the “other” group.³⁸ These situations result in EM students feeling “othered” or “hyper-visible,” like some form of exotic token in comparison with the norm, i.e., the “in-group.”³⁹ There is research highlighting this fact, stating that “schools are cultural contexts that have the power and potential to promote students’ cultural assets or to ‘other’ youths in a way that keeps them from creating meaningful academic identities.”⁴⁰ The “other” minority ethnic group often appears exotic, fascinating, deviant, repugnant, or incomprehensible.³⁹ However, when observing what it means to be the “other,” one uncovers an “overpowering feeling” of being on the outside looking in. This “overpowering feeling” could mean being an EM placed within a culture created to fit the majority or an individual feeling excluded because they do not fit the standard or the norm.⁴¹ As such, we observe an interplay of socially constructed and reconstructed preconceptions of the “Self” and the “Other.” Therefore, othering can build theories of who belongs and who does not belong by denoting the ‘other’ with undesirable connotations, which creates stereotypes and leads to discriminatory behaviors toward students, and eventually impacts their academic performance and wellbeing.⁴²

The impact of othering on ethnic minority students in medical school

Othering in academic settings and the struggle of EM students and faculty to integrate academically are widespread global issues.⁴³ EM students face inequality at all stages of their education and are less likely to enjoy the student experience and are more likely to drop out of school.⁴⁴ Categorization of racial minorities comes in different forms, but racial spotlighting, fascination, and ignoring are three of the more prominent forms of discrimination in school settings.⁴⁵ In the Netherlands, EM individuals (and their offspring) are often referred to as “allochtoon,” which literally means “emerging from another soil.”⁴⁶ The proportion of such EM medical students, doctors, and faculty in Dutch academic institutions is disproportionately low compared to the general population ⁴⁷ and is estimated at roughly 27%.^46,48 Furthermore, these students have lower completion rates on average compared to ethnic majority (i.e., white) Dutch students.⁴⁹

Research on teaching, learning, assessment, and curricular development in medical education has revealed a few issues that can harm the success of EM students in medicine.⁵⁰ For example, research in Dutch universities showed that students who identified as EM were less academically integrated and advanced slower than their ethnic majority peers.⁵¹ Compared to an ethnic majority, these students were less likely to pursue medical careers and scored poorer on preclinical and clinical education knowledge and abilities exams. Compared to the “majority” students, instead of learning, they spent more time struggling with racial discrimination and harassment in the classroom and clinical settings. They also had to deal with implicit biases from residents and patients and experienced severe difficulty qualifying for specialty training.^52–54

In this way, categorization nurtures discrimination, limits understanding, and encourages continued separation and divergence between students. EM students can also be subject to categorizations containing elements of exotic fascination.³⁹ This might happen when peers ask the student to speak for their race or ignore their racial difference at times when subject content may focus on it. Students who are made to feel excluded from the dominant group may never entirely feel integrated or comfortable in educational settings.⁵⁵ Furthermore, the othering of EM students in such exotic and reductive ways places them in an inferior position compared to ethnic majority teachers and students. Moreover, once groups are established, and strong assumptions are formed, the consequence is that stereotyping will diminish an individual’s ability to feel belonging or inclusion, which influences mental well-being and performance within educational settings.¹⁵ So, while research shows that EM medical students underperform compared to ethnic majority students, it is important to acknowledge and resolve the impact of othering, isolation, and discrimination on wellbeing and academic performance (Figure 1).¹⁹

Figure 1. How categorization, othering, and discrimnation impact ethnic minority learners.

Belonging, the antithesis of othering

Othering and belonging are conceptual frameworks that allow us to observe and identify a set of structural processes and dynamics while being sensitive to the specifics of each instance.⁴² The theoretical underpinnings for discrimination and belongingness may be found in psychology. It is based on the premise that individuals need to belong (to a group or community) and feel accepted and supported to succeed in life.⁵⁶ “Belonging” is a person’s subjective sense of profound connection to social groups, physical locations, and individual and communal experiences. Belonging is a basic human desire linked to various positive mental, physical, social, economic, and behavioral effects.⁵⁷

Academic performance, motivation, and effort in school, including medical education, are all greatly influenced by a sense of belonging within the educational setting.⁵⁸ For example, medical students with strong social networks outperform those who feel discriminated against by their professors and peers.⁵⁹ Additionally, The Centers for Disease Control and Prevention (CDC) and the Johnson Foundation at Wingspread’s declaration on school connectedness showed that academic performance is linked with the ability to feel connected.⁶⁰ According to research, medical education connectedness impacts mental health, academic achievement, and outcomes.²⁵ Students’ motivation and classroom engagement also were found to improve when they experienced belonging with their teachers and peers.^61,62 Belonging at medical institutions is essential to achieving successful psychosocial adjustment. It justifies the need for educational institutions to implement interventions that encourage belonging, acceptance, and inclusion. Evidence suggests that the sense of being part of a group of people and not being discriminated against buffers the effects of depression.¹¹ For one to belong, two opposing parties must be involved: the “outsider” who wants to belong and the party with the power to ‘grant’ belonging.⁶³ Belonging at medical institutions is an integral part of successful psychosocial adjustment and offers justification for schools to engage in interventions that promote belonging, acceptance, and inclusion. Belongingness entails a steadfast commitment to tolerating and respecting differences, ensuring that all students feel part of the educational environment. Medical students who feel at home in medical institutions have a greater chance of graduating and obtaining a degree, as formal academic integration is vital in the quality of learning and educational attainment.^64,65 Ed and Sheffler⁶⁶ stated that “the type of environment that a teacher creates and encourages can either increase or decrease a student’s ability to learn and feel comfortable as a member of the class.”⁶⁶

These findings are consistent with a synthesis of publications on the topic performed by the CDC in 2018, which concluded that belonging was associated not only with student-peer relationships but also with peer groups, the educational environment, and society.^57,67 Therefore, the only practical solution to the issue of discrimination in medical schools is one involving inclusion and belongingness, as these institutions arguably offer the second most important set of relationships available to medical students (Figure 2).⁶⁸

Figure 2. How advocacy and inclusion impact sense of belonging in ethnic minority learners.

Way forward

In recent years, the attention paid to diversity, equity, and inclusion in medical education has grown, emphasizing the importance of researching and educating ourselves about othering and belonging among marginalized students in medical education. For example, medical schools have begun incorporating anti-racism education for their staff that focus on learning about the culture of the EM “others.”⁶⁹ However, implementing anti-racism programs with a focus on cultural, ethnic, or racial education does not completely solve the underlying problem of discrimination in education. Incorporating frameworks like critical race theory (CRT), which highlight the underlying mechanisms of racism and discrimination, is important.⁷⁰ CRT provides a framework for understanding power and privilege in education, emphasizing that power is unequally distributed in society and that some groups have more privilege and influence than others. CRT aids in identifying how educational institutions might be rebuilt to be fairer by studying power and privilege in education.⁷¹ In addition, CRT offers an approach to understanding the experiences of students who are othered, stereotyped, and discriminated against based on their race or ethnicity. CRT can allow medical educators to reflect on how racism affects these students’ educational experiences and how education might be changed to better meet their needs by placing the experiences of these students at the center of the discussion.⁷² It is, therefore, important for institutions to note that enabling success will require a holistic approach. An approach that sets out to identify and address othering and discrimination in medical institutions. The program structure can be co-developed with EM members, promoting diversity without tokenism and exoticization and creating specific academic integration programs to promote belonging for EM students.³⁸ Furthermore, institutions are recommended to seek and create an educational climate where EM medical students are empowered to report their negative experiences and have confidence that the university will act on their behalf by rehabilitating or replacing systems and individuals who discriminate.

Similarly, implicit bias training is currently happening in several medical institutions with varying degrees of success.⁷³ This is important as medical educators, program designers, and tutors delivering courses and research must be aware of possible personal biases.¹⁹ However, institutions must continually assess their presumptions about students, including any preconceptions based on race or ethnicity, and change their attitudes, convictions, and actions accordingly. We recommend that medical institutions create a diversity and inclusion committee that includes members of EM groups, students, teachers, and external experts to analyze growth toward inclusive educational spaces for EM students consistently. In conclusion, medical institutions need to recognize that EM students do not constitute a homogeneous group and that strengthening faculty’s ability, diversity, and teaching methods to foster cultural sensitivity is essential.

Concluding remarks

Global migration has resulted in the evolution of several communities made up of diverse groups of people with different backgrounds, ethnicities, and characteristics. This diversity and the need for direction ultimately promoted categorization of people into groups to aid social navigation within these communities. Categorizing individuals into different racial or ethnic groups and the meanings associated with these socially constructed categories account for phenomena such as othering, stereotyping, discrimination, and exclusion. These social constructs consequently have significant implications for individuals and groups in these communities.

Social categorization often leads to othering. Unfortunately, it also occurs in schools, where it can perpetuate racial or ethnic discrimination by reinforcing stereotypes and prejudices toward EM students. Stereotypes undermine the social standing of students, creating an “us versus them” mindset. This in turn, is detrimental and dangerous in academic settings like medical schools. In classrooms for example, EM medical students feel either othered as racially exotic or experience their racial differences being ignored.³⁹ Such discriminatory practices can lead to feelings of exclusion and alienation, hindering academic success and student well-being.

It is crucial to recognize the harmful effects of othering and work toward reducing discrimination, prejudice, and racism by promoting inclusion and belonging. Also, it is vital to acknowledge and challenge the assumptions and biases that underlie many of our social institutions and practices. This requires a willingness to examine personal beliefs and behaviors and to engage in difficult conversations about race, ethnicity, and other forms of difference. Educators and administrators should receive training in cultural humility, which includes understanding and respecting ethnic differences and avoiding stereotypes and biases. Medical schools should also prioritize creating an inclusive environment where EM students feel a sense of belonging. This can include initiatives such as diversifying the curriculum, promoting multiculturalism, and providing resources for students to explore their personal identity. By doing so, we can work toward building a more equitable academic environment where everyone can thrive.

Authors’ reflexivity

OA is a junior career, female, and black academic researcher and physician. JB is a senior career, male and black academic physician, researcher, and clinical leader. Triggered by our different lived experiences as EM scholars, our analysis intends to understand better the mechanisms that hamper equitable learning opportunities in medical education. We also intended to explore the social constructs of othering and belonging, which can positively influence the progress and success of EM groups in medical education. We reexamined these concepts to present potential recommendations for solutions. In summary, our review offers (new) thinking on how to frame current concepts and promote equitable opportunities for marginalized medical trainees through the lens of peers who have experienced and succeeded in inequitable systems.⁷⁴

Authors’ contributions

All authors contributed to the study’s conception and design. OA and JOB did material preparation and literature review. OA wrote the first draft of the manuscript, and JOB commented on and edited the initial and subsequent versions. All authors read and approved the final manuscript.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.