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Professional identity formation for underrepresented groups in medicine: challenges and interventions for Dutch medical schools: a systematic scoping review

PMCID: PMC12746619

PMID: 41454317

Abstract

Background The concept of intersectionality is important when considering the professional identity formation (PIF) of students who are racially and ethnically underrepresented in medicine (URiM), as they must navigate race and ethnicity within the medical landscape. Despite a growing body of studies that shed light on the challenges that URiM students face in their PIF, there remains a notable lack of practical interventions for medical schools to address these challenges. Our objective is to highlight the challenges faced by URiM students and identify interventions in the literature that would be most suitable for Dutch medical schools to address them. Methods This study builds upon Teo et al.‘s (2022) scoping review. We examined articles from January 1, 2000, to December 31, 2021, and conducted an extended search from January 1, 2022, to November 30, 2023. Our focus was on articles exploring the intersectionality of PIF, perspectives of minoritized groups, and diversity, equity, and inclusion (DEI) within the context of PIF in medical education. We used the Systematic Evidence-Based Approach (SEBA) guided systematic scoping review, encompassing four stages: Systematic Approach, Structured Summary and Synthesis, Jigsaw Perspective, and Literature Analysis. Results A total of 692 abstracts were reviewed, 36 full-text articles were evaluated, and 22 articles were included. URiM students encounter multiple challenges in their PIF journeys such as a lack of role models and representation, experiences of microaggressions, and pressure to assimilate into the majority culture. The proposed interventions for medical schools included diversifying recruitment practices to create more role models, developing curricula to address these challenges, and establishing a supportive network for URiM students. Conclusions Our study highlights the pressing need for Dutch medical schools to address the challenges faced by URiM students in PIF. The identified interventions offer actionable strategies to cultivate a more supportive and equitable learning environment. The implementation of these interventions has the potential to enhance URiM students’ educational experiences, reduce disparities, and promote diversity within the medical profession. These findings underscore the importance of ongoing efforts to prioritize inclusivity and equity in medical education. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-025-07811-6.

Full Text

In many Global North contexts, the healthcare sector faces persistent underrepresentation issues. The term Global North is not a geographical designation, rather it refers to economically and technologically developed, wealthy nations and thus includes countries in North America, Western Europe, as well as Australia and some parts of Asia [1]. Many of these nations also have ethnically diverse populations due to histories linked to colonialism and/or more recent waves of labor migration, yet this societal diversity is not necessarily reflected in the medical profession. For instance, in the United States only 7% of physicians and 12.5% of physician assistants belong to underrepresented in medicine (URiM) groups [2]. Until the mid-19th century, Black students were systematically excluded from most U.S. medical schools, with only a few institutions in the North and East admitting a limited number of Black students [3]. Once they graduated, Black doctors were confined to segregated healthcare settings, where they exclusively cared for Black patients and assumed subordinate roles to White physicians [4]. Following 1865, seven historically Black medical colleges were established [3]. However, the implementation of Abraham Flexner’s 1910 medical education reforms led to the closure of all but two of these institutions [5], further restricting opportunities for Black students and perpetuating racial disparities in medical education and the physician workforce.
In the Netherlands, the pressing concern of underrepresentation is similarly evident, as the medical specialist population fails to reflect the diversity observed in both the general population and among medical students [6]. For instance, only 2–4% of medical specialists have a migration background, meaning they have at least one parent who was born outside the Netherlands, compared to 21% of medical students. Additionally, Turkish-Dutch and Moroccan-Dutch individuals, who constitute 4.8% of the population, represent just 1.6% of physicians and 1.2% of specialists [6]. These disparities highlight a ‘leaky pipeline’ effect in the transition from medical education to professional practice, further limiting opportunities for URiM students to find relatable role models within the profession [6].
Further, professional identity formation (PIF) is a critical process for medical students, involving the internalization of norms, values, and behaviors necessary to “think, act, and feel like a physician” [7]. This developmental process is influenced by interactions with peers, mentors, and the broader medical community [7–9]. However, URiM students—defined as those racial and ethnic populations underrepresented in the medical profession relative to their numbers in the general population [10]—could face challenges that can hinder PIF.
Dutch medical schools face many of the same problems related to URiM students as described in studies originating in other countries. However, certain cultural and historical factors unique to the Netherlands bear consideration. While the Netherlands is an ethnically diverse country (25% of Dutch residents were first- or second-generation migrants as of 2022) [11], it is only in recent years that many societal discussions around race, institutional racism and discrimination against minoritized groups, and related issues like decolonization have begun. What is perhaps distinctive about the Dutch context is what anthropologist Gloria Wekker has described as “White innocence,” which refers to how hegemonic, White Dutch identities are built on self-images of innocence and goodness, of being a highly tolerant, civilized nation that champions human rights, while at the same time invisibilizing national colonial histories and the experiences of post-colonial (Surinamese and Indonesian) and migrant (Turkish, Moroccan, and others) populations [12]. In other words, racialized white identities are coded in highly positive moral terms, while those racialized as non-white are not.
In the Dutch medical field, normative whiteness underpins the “cultural cloning” of physicians [13]. Attempts are being made to publicly address historical and contemporary sources of inequity. For example, the Dutch king recently acknowledged and apologized for the Netherlands’ historical role in the colonial slave trade [14]. In addition, diversity, equity, and inclusion offices have been established in many public organizations like universities and in the private sector in the last few years. At the same time, a recent government report showed widespread individual experiences of discrimination as related to cultural and other forms of difference [15], and in the medical profession in particular, minoritized ethnic groups are systematically extremely underrepresented [6, 16]. At the national level, a recent dramatic rise in rightwing populist rhetoric that stigmatizes immigrants and fuels anxieties about cultural integration has culminated in the right-wing party, Party for Freedom (PVV) becoming the largest political faction in government since 2023 [17, 18]. Thus identifying actionable strategies to support the professional identity formation of URiM students is of both urgent institutional and public importance.
In addition to being underrepresented, students with ‘non-Western migrant’1backgrounds at all Dutch universities have higher dropout rates and slower study progress than their ethnic Dutch peers [19]. The higher dropout rates among students from minoritized groups may be attributed to a lack of adequate role models and experiences of active discrimination [20–22]. These challenges could potentially impact the PIF of current Dutch URiM students. Studies indicate that the concept of intersectionality plays a crucial role in PIF, as students navigate the intersection of race and ethnicity within the medical landscape [23]. The term ‘intersectionality,’ coined by law scholar Kimberlé Crenshaw, describes how multiple elements of an individual’s social identity, such as race, class, and gender, interact in real-time to create and perpetuate societal inequalities and discrimination [24].
Krishna’s Ring Theory of Personhood expands on this by examining how societal, cultural, and professional expectations shape medical students’ identities [25]. It highlights that conflicts between these external expectations and a student’s personal or cultural identities can lead to “disharmony” or even “dyssynchrony” [25]. To address these tensions, students may employ strategies like “patching,” where they adopt an ‘ideal’ identity to bridge gaps in their professional identity, or “splinting,” relying on past identities to protect their current, fragile sense of self. This contextual understanding becomes crucial when considering the challenges confronting URiM students in their PIF.
An increasing number of students from ‘non-Western migrant’ backgrounds are enrolling in Dutch medical schools, with the percentage of first-generation students growing from 2.4% in 2018 to 3.1% in 2023, and that of second-generation students increasing from 7.2% in 2018 to 9.4% in 2023 [26]. The rise in enrollment of minoritized students in Dutch medical schools signifies progress towards a more diverse medical workforce, ensuring that medicine more accurately represents and reflects the patient body it serves. Simultaneously, this growth emphasizes the need for Dutch medical schools to address the challenges faced by URiM students in their PIF and to support them accordingly. Additionally, the discourse surrounding DEI within Dutch medical schools shows that normalization practices in academic hospitals often obscure diversity and hinder the inclusion of culturally minoritized professionals [27]. These practices frame professionalism as neutral and equate equality with sameness, perpetuating an unequal distribution of privilege and disadvantage among professionals. Such cultural norms and organizational structures contribute to entrenching the difficulties URiM students face in their PIF.
This systematic scoping review builds upon the foundational work of Teo et al. (2022), which explored how cultural, religious, and societal influences shape the complex process of PIF in medical students [25]. Teo et al.‘s insights provided a valuable starting point for addressing the challenges faced by URIM groups. Additionally, Teo et al.‘s expansive coverage of the articles from 2000 to 2021 ensures a broad spectrum of literature for our analysis. Their inclusion and exclusion criteria were designed to identify studies relevant to PIF among medical students. Our study built upon their methodology but refined it by adding a critical criterion: all selected articles were required to explicitly address DEI, intersectionality, or provide meaningful insights into the experiences of minoritized groups within the context of PIF. Articles were sourced globally to ensure a comprehensive understanding of underrepresentation and diversity in medical education.
We recognized a scarcity of articles within Teo et al.’s included studies that align with our inclusion criteria. To enhance our approach, we conducted backward and forward snowballing on the included articles, but this process yielded no relevant articles. To address the scarcity of articles specifically centered on the intersectionality of PIF, DEI, and URiM perspectives, we therefore conducted an extended search from January 1, 2022, to November 30, 2023, using the same search string employed by Teo et al. [25]. This focus allowed us to assess how aspects of diversity are integrated or overlooked in the PIF literature for medical students. Our search yielded 1,001 articles from four databases: PubMed (287), Embase (356), Scopus (288), and ERIC (70). After removing 309 duplicates, we screened 692 records by title and abstract for relevance to DEI, URiM populations, and PIF. Following the application of exclusion criteria, 656 studies were excluded. Next, 36 articles underwent full-text review. Of these, 23 were excluded based on the inclusion and exclusion criteria, leaving 13 eligible studies. Additionally, to ensure comprehensiveness, backward and forward snowballing was conducted for these 13 studies, identifying nine more articles. This process resulted in a total of 22 articles for detailed analysis.
Figure 1 presents the PRISMA flowchart summarizing the screening and selection process. For transparency and reproducibility, the detailed search strategy is provided in Appendix A, and a tabulated summary of the 22 included articles is available in Appendix B.
To ensure methodological consistency, we adopted the Systematic Evidence-Based Approach (SEBA) for our systematic scoping review, following the methodology outlined by Teo et al. [25]. We followed the four stages of SEBA as outlined by the authors and provide a description below of how this approach was applied to our research question.
URiM groups not only encounter obstacles in their journey toward becoming medical specialists [6] but also encounter a myriad of challenges in their PIF. In the following section, we delineate these challenges, addressing issues such as a lack of role models and representation, experiences of microaggressions, and pressure to assimilate into the majority culture. Appendix B further illustrates the information derived from the included studies.
Insufficient role models and mentorship present a challenge for URiM groups, with URiM 196 groups expressing a longing for mentors. [21, 28, 29] In studies, URiM professionals reported 197 feeling the need to act as positive role models for others with minoritized backgrounds due to a 198 lack of role models for themselves. This mentoring activity can be characterized as participating 199 in ‘racial uplift’. [2, 30, 31]Racial uplift is a double-sided process. On the one hand, URiM 200 professionals integrate their racial and professional identities by giving back to their 201 communities of origin for the support they received in pursuing educational and professional 202 goals; [30] on the other hand, URiM professionals are expected to present and advocate for their 203 communities, constituting an additional burden, described as the ‘minority tax’ [32].
Another challenge faced by URiM groups is the experience of multiple forms of microaggressions from various sources, including fellow students, faculty, guest lecturers, and administrators [2, 20]. They describe feelings of heightened visibility due to their skin color and encounters with patients who refuse their care based on racial bias, thereby highlighting pervasive discrimination within healthcare [20]. Additionally, participants discussed the added pressure of having to work twice as hard because they felt scrutinized more stringently due to the color of their skin and a stronger sense of being under a microscope in comparison with their White counterparts [20]. These instances illustrate the stress URiM students face as they balance professional learning with the imperative to prove their worth in a demanding environment, emphasizing the profound impact of microaggressions. Most notably, microaggressions can lead to depressive symptoms which can ultimately hinder academic advancement in medicine [33].
URiM groups face pressure to assimilate into the majority culture, leading them to adjust their behavior accordingly [2, 34]. For example, in one study, a Black orthopedic surgery student revealed a constant need to suppress expressions of anger to avoid conforming to the stereotype of the ‘angry Black woman’ [34].
URiM groups also experience pressure to conform to Eurocentric beauty standards [35]. This aligns with broader scholarly studies demonstrating that individuals, particularly Black women, may internalize European beauty ideals [37]. Similarly, certain Black medical students adopt strategic measures, such as employing a ring light, to present a lighter complexion during residency interviews, which exemplifies the effects of colorism [35]. These observations align with the concept of ‘double consciousness,’ wherein students with minoritized identities navigate society with a dual awareness [36]. URiM physicians may grapple with an internal conflict due to ‘double consciousness’—that is, belonging to the medical in-group while not conforming to the prototypical identity of a physician [38].
Studies mention that increased representation of diverse role models is essential for fostering an inclusive and supportive environment [2, 39]. Mentorship strengthens the in-group cohesion of medical students and contributes to identity-safe environments [38]. It can also contribute to a strong sense of belonging, which can in turn lead to more students staying in college and graduating [40].
To achieve the presence of more diverse role models, studies suggest various approaches. These include diversifying recruitment practices and intentionally recruiting individuals from URiM backgrounds to invite them into the profession [2, 39]. This can enhance URiM students’ sense of support, mentorship, and belonging within the medical school community [39], and help create an environment that promotes academic development psychological safety [2].
The I-CA2R2E framework, originally developed to support medical students in their PIF, outlines strategies such as fostering individual connections, acknowledging students’ experiences, adjusting education to be more inclusive, and role modeling [41]. One study noted the framework’s potential for addressing the unique challenges faced by URiM students [29].
Studies additionally suggest that minoritized professionals should have more access to leadership positions within academic medicine [30]. Compared to their non-URiM counterparts, URiM faculty members express greater aspirations for leadership in academic medicine; however, they experience lower levels of inclusion, trust, and relationships within the academic environment. To address the leadership aspirations of URiM physicians, it is crucial to focus on the leadership ambitions of this group. These leadership opportunities should encompass positions at the institutional level [30].
Another proposed intervention in medical education is to make room to share lived experience narratives with students. Banks’s theory of multicultural education highlights the positive significance of integrating a curriculum that reflects the lived experiences of minoritized individuals and is grounded in equity pedagogy [42]. In the educational context, narratives based on lived experiences can be leveraged to deepen understanding, cultivate empathy, and enhance cultural competence [42]. One suggested intervention in medical education includes incorporating a professionalism module focused on sharing experiential narratives into the curriculum [43]. In this module, physicians, including those from underrepresented groups, can be invited to recount career-defining moments that necessitated reconciling personal and professional identities. The presence of URiM physicians could contribute to a heightened sense of belonging and an increased sense of representation for URiM students.
Studies indicate that the socialization process in medical education can create pressure for URiM students to assimilate into the dominant culture, which may conflict with their existing values and beliefs [44].
Research also highlights that PIF is influenced by values and ontological systems cultivated during childhood, suggesting that students should be given more time to reflect on their diverse perspectives and backgrounds during their medical training [44]. Faculty-student interactions, such as small-group sessions or one-on-one meetings, are identified as opportunities to better understand students’ values, beliefs, and practices shaped by their upbringing and communities [44, 45].
Moreover, studies emphasize the importance of addressing socioeconomic experiences, privilege, and underprivilege in medical education to address disparities among medical students [44]. Doing so can contribute to an environment where medical students from underprivileged backgrounds feel more easily seen and understood by their peers and educators. Additionally, it broadens medical students’ understanding of patients from disadvantaged backgrounds, which could shape their PIF. To facilitate discussions on sensitive topics such as socioeconomic experiences and privilege, educators are encouraged to create a safe space for medical students to engage in these conversations. This involves remaining attentive to inadvertent microaggressions that may arise during these discussions [44, 46].
Lastly, it is also acknowledged that minoritized individuals play an active role in cultivating a sense of identity safety for themselves by addressing the challenges that they face [21]. Minoritized individuals contribute proactively to their psychological and educational well-being. They engage in behaviors such as seeking mentors with similar identities, engaging with leadership for accommodations, and fostering a sense of belonging, all of which contribute to this proactive sense of safety [21]. Additionally, studies highlight the positive impact of diverse identities, which are viewed not only as challenges but as assets that enhance patient care through effective communication and unique perspectives [21].
Out of the 22 articles included in this study, only six presented concrete approaches to address the challenges faced in PIF. Table 1 provides a comprehensive overview of these articles, summarizing key interventions proposed in the literature to address challenges in PIF for URiM groups [2, 30, 31, 39, 43, 45].
Normative practices refer to established customs, behaviors, or procedures within an institution that reflect dominant cultural norms or values [47]. Historically, normative practices in medical schools included segregationist policies that excluded Blacks/African Americans from medical education [3]. Contemporary normative practices within medical schools may encompass the belief that norms of medical professionalism are deeply rooted in the historical and Eurocentric portrayal of a physician, leading to instances where URiM groups report being scrutinized or singled out based on their cultural or ethnic attributes [2, 35].
The norm group comprises individuals who adhere to the dominant cultural norms or values within a given context. For example, medical students in Dutch medical schools are disproportionately likely to have parents with a very high income [48]. In 2020, 56.3% of first-year medical students had at least one parent within the top 10% highest-income earners in the Netherlands. This shows that the norm group among Dutch medical students primarily consists of individuals from higher socioeconomic backgrounds [48].
Several interventions identified in this study targeted both the norm group and minoritized groups. For instance, adapting medical curricula to incorporate diverse narratives, including sharing the lived experiences of minoritized individuals, benefits both URiM students and students from the norm group [42, 43]. By introducing diverse narratives into the curriculum, this approach disrupts existing normative practices that may perpetuate exclusivity and bias.
Additionally, some interventions focus on educating medical educators about the socialization process in medical education. Studies indicate that this process can create pressure for URiM students to assimilate into the dominant culture, which may conflict with their existing values and beliefs [44]. By promoting awareness of this socialization process, educators can help students navigate the tension between their cultural identity and the expectations of the medical profession. In doing so, these interventions seek to disrupt normative practices that perpetuate a singular, often homogeneous view of the medical profession. The I-CA2R2E framework addresses normative practices, the needs of minoritized groups, as well as the norm group [29, 41]. By encouraging self-awareness and reflection among faculty members, it challenges existing norms. Simultaneously, it could provide essential role models for URiM students, enhancing their sense of belonging. Additionally, it fosters individual connections and open exchanges, creating supportive relationships that directly benefit minoritized individuals in predominantly White institutions.
Fostering identity safety tends to focus primarily on individuals from minoritized groups. This intervention suggests that URiM individuals should actively contribute to their well-being by seeking mentors with similar identities, engaging with leadership for support, and fostering a sense of belonging, which can enhance their identity safety [21]. Another intervention focuses on the recruitment and leadership opportunities for URiM faculty. Actively recruiting URiM faculty and providing access to leadership positions can make medical schools a more inclusive environment [30]. This approach focuses on supporting minoritized groups by providing resources to them specifically, rather than addressing normative practices. However, it is noted that recruitment alone may not be sufficient to bring about lasting changes in normative practices, and broader strategies targeting institutional policies and culture may be needed for enduring impact.
Insufficient role models and mentorship remain a challenge for URiM groups, who often express a longing for mentors with similar identities [29]. This need for role models is strongly felt by Dutch URiM students as well [28]. Dutch URiM alumni have expressed that having more doctors from minority backgrounds would have been beneficial for them [28]. Many URiM professionals engage in racial uplift by taking on mentoring roles to support others and give back to their communities [30]. Additionally, they experience the burden of the ‘minority tax’ [32].
Microaggressions remain a pervasive challenge for URiM students with reports of discriminatory interactions involving peers, faculty, and patients [2, 20]. Many students describe heightened visibility due to their racial or ethnic identity, often encountering discriminatory experiences such as patients refusing care based on racial bias [20]. This heightened scrutiny exacerbates the pressure to perform exceptionally, as URiM students feel pressured to demonstrate their competence more than their White counterparts [20]. Such persistent pressure can adversely impact the academic and professional success of URiM students [33].
In the Netherlands, similar patterns emerge among Dutch URiM students. Many report feeling discriminated against based on their ethnic, cultural, and/or religious identity, particularly in specific parts of the curriculum such as group discussions on biases, case studies, and practical training sessions [49]. In these situations, Dutch URiM students often remain quiet to avoid further scrutiny [50].
Moreover, a qualitative interview study of female Muslim medical students in the Netherlands reported that certain characteristics, such as wearing a headscarf or speaking with a foreign accent, were associated with being perceived as ‘different’ and contributed to feelings of exclusion [50]. Respondents reported microaggressions, like being told they couldn’t be ‘neutral’ because of their headscarf [50]. Such tensions underscore the challenges URiM students face in reconciling their personal and professional identities in a medical environment.
Studies report that URiM groups face substantial pressure to assimilate into the majority culture to align with Eurocentric standards of professionalism [34, 35]. This is evident in behaviors such as suppressing emotional expressions to avoid conforming to racial stereotypes, such as the “angry Black woman” [35]. Furthermore, some Black students strategically alter their appearance, including using ring lights to present a lighter complexion during residency interviews, underscoring the pervasive effects of colorism [35, 37, 51].
Professional appearance norms further perpetuate stereotype threats, as seen in white coat ceremonies where directives on ethnic hairstyles, such as keeping them “neat,” implicitly suggest these styles are less professional [2]. These norms reflect societal biases, positioning Eurocentric features as ideal while framing cultural attributes as deviations. This dynamic forces URiM students to navigate “double consciousness,” balancing their cultural identity with the expectations of the medical profession, complicating their PIF [38]. Although these findings are results related to American medical educational settings, it is possible that Dutch URiM students encounter similar pressures. As a minority in medical environments, they may experience comparable biases and societal expectations regarding professional appearance.
Studies suggest that it is not sufficient for institutions to wait for racially minoritized individuals to express interest in the medical profession. Instead, schools should actively reach out to these communities and invite them into their programs [2]. Although URiM physicians often engage in racial uplift by mentoring URiM students, this responsibility should not rest solely on them [31]. A study recommends that this burden be shared among all medical educators, transitioning from a minority tax to a collective responsibility [30]. To facilitate this shift, academic institutions should implement robust training programs for non-URiM physicians to prepare them for mentoring URiM students [31]. These programs can help mentors understand the sociohistorical context of URiM students, enabling effective support in integrating their racial and professional identities.
Studies indicate that the socialization process in medical education often pressures URiM students to assimilate into the dominant culture, conflicting with their existing values and beliefs [44]. Medical educators should critically reevaluate this process and move away from attempting to mold students into a predetermined image of the “right kind of doctor” [44]. Instead, educators should focus on teaching students about their socialization process, acknowledging that PIF is influenced by childhood values and broader ontological systems [44].
Additionally, educators should strive to understand students’ values, beliefs, and practices shaped by their home communities. This can be achieved through explicit conversations about identity construction, clarifying goals, and providing small-group or one-on-one interactions to guide students on their professional journeys [45].
Minoritized individuals play an active role in cultivating a sense of identity safety by addressing the challenges they face [21]. They proactively contribute to their psychological and educational well-being by seeking mentors with similar identities and fostering a sense of belonging. Shifting the focus from external factors to individual agency highlights the empowering role of diverse identities in creating a supportive and safe learning environment [21].
Finally, a comparative analysis across countries with diverse healthcare and educational systems could identify both universal challenges faced by URiM students and culturally specific solutions. These research directions will help expand our understanding of the factors influencing URiM students’ PIF and the role that institutional practices and interventions play in shaping their experiences. Table 2 outlines these recommendations for further exploration.

Sections

"[{\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR1\", \"CR2\", \"CR3\", \"CR4\", \"CR3\", \"CR5\"], \"section\": \"Background\", \"text\": \"In many Global North contexts, the healthcare sector faces persistent underrepresentation issues. The term Global North is not a geographical designation, rather it refers to economically and technologically developed, wealthy nations and thus includes countries in North America, Western Europe, as well as Australia and some parts of Asia [1]. Many of these nations also have ethnically diverse populations due to histories linked to colonialism and/or more recent waves of labor migration, yet this societal diversity is not necessarily reflected in the medical profession. For instance, in the United States only 7% of physicians and 12.5% of physician assistants belong to underrepresented in medicine (URiM) groups [2]. Until the mid-19th century, Black students were systematically excluded from most U.S. medical schools, with only a few institutions in the North and East admitting a limited number of Black students [3]. Once they graduated, Black doctors were confined to segregated healthcare settings, where they exclusively cared for Black patients and assumed subordinate roles to White physicians [4]. Following 1865, seven historically Black medical colleges were established [3]. However, the implementation of Abraham Flexner\\u2019s 1910 medical education reforms led to the closure of all but two of these institutions [5], further restricting opportunities for Black students and perpetuating racial disparities in medical education and the physician workforce.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR6\", \"CR6\", \"CR6\"], \"section\": \"Background\", \"text\": \"In the Netherlands, the pressing concern of underrepresentation is similarly evident, as the medical specialist population fails to reflect the diversity observed in both the general population and among medical students [6]. For instance, only 2\\u20134% of medical specialists have a migration background, meaning they have at least one parent who was born outside the Netherlands, compared to 21% of medical students. Additionally, Turkish-Dutch and Moroccan-Dutch individuals, who constitute 4.8% of the population, represent just 1.6% of physicians and 1.2% of specialists [6]. These disparities highlight a \\u2018leaky pipeline\\u2019 effect in the transition from medical education to professional practice, further limiting opportunities for URiM students to find relatable role models within the profession [6]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR7\", \"CR7\", \"CR9\", \"CR10\"], \"section\": \"Background\", \"text\": \"Further, professional identity formation (PIF) is a critical process for medical students, involving the internalization of norms, values, and behaviors necessary to \\u201cthink, act, and feel like a physician\\u201d [7]. This developmental process is influenced by interactions with peers, mentors, and the broader medical community [7\\u20139]. However, URiM students\\u2014defined as those racial and ethnic populations underrepresented in the medical profession relative to their numbers in the general population [10]\\u2014could face challenges that can hinder PIF.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR11\", \"CR12\"], \"section\": \"Background\", \"text\": \"Dutch medical schools face many of the same problems related to URiM students as described in studies originating in other countries. However, certain cultural and historical factors unique to the Netherlands bear consideration. While the Netherlands is an ethnically diverse country (25% of Dutch residents were first- or second-generation migrants as of 2022) [11], it is only in recent years that many societal discussions around race, institutional racism and discrimination against minoritized groups, and related issues like decolonization have begun. What is perhaps distinctive about the Dutch context is what anthropologist Gloria Wekker has described as \\u201cWhite innocence,\\u201d which refers to how hegemonic, White Dutch identities are built on self-images of innocence and goodness, of being a highly tolerant, civilized nation that champions human rights, while at the same time invisibilizing national colonial histories and the experiences of post-colonial (Surinamese and Indonesian) and migrant (Turkish, Moroccan, and others) populations [12]. In other words, racialized white identities are coded in highly positive moral terms, while those racialized as non-white are not.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR13\", \"CR14\", \"CR15\", \"CR6\", \"CR16\", \"CR17\", \"CR18\"], \"section\": \"Background\", \"text\": \"In the Dutch medical field, normative whiteness underpins the \\u201ccultural cloning\\u201d of physicians [13]. Attempts are being made to publicly address historical and contemporary sources of inequity. For example, the Dutch king recently acknowledged and apologized for the Netherlands\\u2019 historical role in the colonial slave trade [14]. In addition, diversity, equity, and inclusion offices have been established in many public organizations like universities and in the private sector in the last few years. At the same time, a recent government report showed widespread individual experiences of discrimination as related to cultural and other forms of difference [15], and in the medical profession in particular, minoritized ethnic groups are systematically extremely underrepresented [6, 16]. At the national level, a recent dramatic rise in rightwing populist rhetoric that stigmatizes immigrants and fuels anxieties about cultural integration has culminated in the right-wing party, Party for Freedom (PVV) becoming the largest political faction in government since 2023 [17, 18]. Thus identifying actionable strategies to support the professional identity formation of URiM students is of both urgent institutional and public importance.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"Fn1\", \"CR19\", \"CR20\", \"CR22\", \"CR23\", \"CR24\"], \"section\": \"Background\", \"text\": \"In addition to being underrepresented, students with \\u2018non-Western migrant\\u20191backgrounds at all Dutch universities have higher dropout rates and slower study progress than their ethnic Dutch peers [19]. The higher dropout rates among students from minoritized groups may be attributed to a lack of adequate role models and experiences of active discrimination [20\\u201322]. These challenges could potentially impact the PIF of current Dutch URiM students. Studies indicate that the concept of intersectionality plays a crucial role in PIF, as students navigate the intersection of race and ethnicity within the medical landscape [23]. The term \\u2018intersectionality,\\u2019 coined by law scholar Kimberl\\u00e9 Crenshaw, describes how multiple elements of an individual\\u2019s social identity, such as race, class, and gender, interact in real-time to create and perpetuate societal inequalities and discrimination [24]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR25\", \"CR25\"], \"section\": \"Background\", \"text\": \"Krishna\\u2019s Ring Theory of Personhood expands on this by examining how societal, cultural, and professional expectations shape medical students\\u2019 identities [25]. It highlights that conflicts between these external expectations and a student\\u2019s personal or cultural identities can lead to \\u201cdisharmony\\u201d or even \\u201cdyssynchrony\\u201d [25]. To address these tensions, students may employ strategies like \\u201cpatching,\\u201d where they adopt an \\u2018ideal\\u2019 identity to bridge gaps in their professional identity, or \\u201csplinting,\\u201d relying on past identities to protect their current, fragile sense of self. This contextual understanding becomes crucial when considering the challenges confronting URiM students in their PIF.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR26\", \"CR27\"], \"section\": \"Background\", \"text\": \"An increasing number of students from \\u2018non-Western migrant\\u2019 backgrounds are enrolling in Dutch medical schools, with the percentage of first-generation students growing from 2.4% in 2018 to 3.1% in 2023, and that of second-generation students increasing from 7.2% in 2018 to 9.4% in 2023 [26]. The rise in enrollment of minoritized students in Dutch medical schools signifies progress towards a more diverse medical workforce, ensuring that medicine more accurately represents and reflects the patient body it serves. Simultaneously, this growth emphasizes the need for Dutch medical schools to address the challenges faced by URiM students in their PIF and to support them accordingly. Additionally, the discourse surrounding DEI within Dutch medical schools shows that normalization practices in academic hospitals often obscure diversity and hinder the inclusion of culturally minoritized professionals [27]. These practices frame professionalism as neutral and equate equality with sameness, perpetuating an unequal distribution of privilege and disadvantage among professionals. Such cultural norms and organizational structures contribute to entrenching the difficulties URiM students face in their PIF.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR25\"], \"section\": \"Methods\", \"text\": \"This systematic scoping review builds upon the foundational work of Teo et al. (2022), which explored how cultural, religious, and societal influences shape the complex process of PIF in medical students [25]. Teo et al.\\u2018s insights provided a valuable starting point for addressing the challenges faced by URIM groups. Additionally, Teo et al.\\u2018s expansive coverage of the articles from 2000 to 2021 ensures a broad spectrum of literature for our analysis. Their inclusion and exclusion criteria were designed to identify studies relevant to PIF among medical students. Our study built upon their methodology but refined it by adding a critical criterion: all selected articles were required to explicitly address DEI, intersectionality, or provide meaningful insights into the experiences of minoritized groups within the context of PIF. Articles were sourced globally to ensure a comprehensive understanding of underrepresentation and diversity in medical education.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR25\"], \"section\": \"Methods\", \"text\": \"We recognized a scarcity of articles within Teo et al.\\u2019s included studies that align with our inclusion criteria. To enhance our approach, we conducted backward and forward snowballing on the included articles, but this process yielded no relevant articles. To address the scarcity of articles specifically centered on the intersectionality of PIF, DEI, and URiM perspectives, we therefore conducted an extended search from January 1, 2022, to November 30, 2023, using the same search string employed by Teo et al. [25]. This focus allowed us to assess how aspects of diversity are integrated or overlooked in the PIF literature for medical students. Our search yielded 1,001 articles from four databases: PubMed (287), Embase (356), Scopus (288), and ERIC (70). After removing 309 duplicates, we screened 692 records by title and abstract for relevance to DEI, URiM populations, and PIF. Following the application of exclusion criteria, 656 studies were excluded. Next, 36 articles underwent full-text review. Of these, 23 were excluded based on the inclusion and exclusion criteria, leaving 13 eligible studies. Additionally, to ensure comprehensiveness, backward and forward snowballing was conducted for these 13 studies, identifying nine more articles. This process resulted in a total of 22 articles for detailed analysis.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"Fig1\"], \"section\": \"Methods\", \"text\": \"Figure 1 presents the PRISMA flowchart summarizing the screening and selection process. For transparency and reproducibility, the detailed search strategy is provided in Appendix A, and a tabulated summary of the 22 included articles is available in Appendix B.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR25\"], \"section\": \"SEBA approach\", \"text\": \"To ensure methodological consistency, we adopted the Systematic Evidence-Based Approach (SEBA) for our systematic scoping review, following the methodology outlined by Teo et al. [25]. We followed the four stages of SEBA as outlined by the authors and provide a description below of how this approach was applied to our research question.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR6\"], \"section\": \"Results\", \"text\": \"URiM groups not only encounter obstacles in their journey toward becoming medical specialists [6] but also encounter a myriad of challenges in their PIF. In the following section, we delineate these challenges, addressing issues such as a lack of role models and representation, experiences of microaggressions, and pressure to assimilate into the majority culture. Appendix B further illustrates the information derived from the included studies.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR21\", \"CR28\", \"CR29\", \"CR2\", \"CR30\", \"CR31\", \"CR30\", \"CR32\"], \"section\": \"Lack of role models and minority tax\", \"text\": \"Insufficient role models and mentorship present a challenge for URiM groups, with URiM 196 groups expressing a longing for mentors. [21, 28, 29] In studies, URiM professionals reported 197 feeling the need to act as positive role models for others with minoritized backgrounds due to a 198 lack of role models for themselves. This mentoring activity can be characterized as participating 199 in \\u2018racial uplift\\u2019. [2, 30, 31]Racial uplift is a double-sided process. On the one hand, URiM 200 professionals integrate their racial and professional identities by giving back to their 201 communities of origin for the support they received in pursuing educational and professional 202 goals; [30] on the other hand, URiM professionals are expected to present and advocate for their 203 communities, constituting an additional burden, described as the \\u2018minority tax\\u2019 [32]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR20\", \"CR20\", \"CR20\", \"CR33\"], \"section\": \"Microaggressions\", \"text\": \"Another challenge faced by URiM groups is the experience of multiple forms of microaggressions from various sources, including fellow students, faculty, guest lecturers, and administrators [2, 20]. They describe feelings of heightened visibility due to their skin color and encounters with patients who refuse their care based on racial bias, thereby highlighting pervasive discrimination within healthcare [20]. Additionally, participants discussed the added pressure of having to work twice as hard because they felt scrutinized more stringently due to the color of their skin and a stronger sense of being under a microscope in comparison with their White counterparts [20]. These instances illustrate the stress URiM students face as they balance professional learning with the imperative to prove their worth in a demanding environment, emphasizing the profound impact of microaggressions. Most notably, microaggressions can lead to depressive symptoms which can ultimately hinder academic advancement in medicine [33]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR34\", \"CR34\"], \"section\": \"Pressure to assimilate into the majority culture\", \"text\": \"URiM groups face pressure to assimilate into the majority culture, leading them to adjust their behavior accordingly [2, 34]. For example, in one study, a Black orthopedic surgery student revealed a constant need to suppress expressions of anger to avoid conforming to the stereotype of the \\u2018angry Black woman\\u2019 [34]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR35\", \"CR37\", \"CR35\", \"CR36\", \"CR38\"], \"section\": \"Pressure to assimilate into the majority culture\", \"text\": \"URiM groups also experience pressure to conform to Eurocentric beauty standards [35]. This aligns with broader scholarly studies demonstrating that individuals, particularly Black women, may internalize European beauty ideals [37]. Similarly, certain Black medical students adopt strategic measures, such as employing a ring light, to present a lighter complexion during residency interviews, which exemplifies the effects of colorism [35]. These observations align with the concept of \\u2018double consciousness,\\u2019 wherein students with minoritized identities navigate society with a dual awareness [36]. URiM physicians may grapple with an internal conflict due to \\u2018double consciousness\\u2019\\u2014that is, belonging to the medical in-group while not conforming to the prototypical identity of a physician [38]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR39\", \"CR38\", \"CR40\"], \"section\": \"Increasing diverse role models\", \"text\": \"Studies mention that increased representation of diverse role models is essential for fostering an inclusive and supportive environment [2, 39]. Mentorship strengthens the in-group cohesion of medical students and contributes to identity-safe environments [38]. It can also contribute to a strong sense of belonging, which can in turn lead to more students staying in college and graduating [40]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR39\", \"CR39\", \"CR2\"], \"section\": \"Increasing diverse role models\", \"text\": \"To achieve the presence of more diverse role models, studies suggest various approaches. These\\u00a0include diversifying recruitment practices and intentionally recruiting individuals from URiM\\u00a0backgrounds to invite them into the profession [2, 39]. This can enhance URiM students\\u2019 sense\\u00a0of support, mentorship, and belonging within the medical school community [39], and help\\u00a0create an environment that promotes academic development psychological safety [2].\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR41\", \"CR29\"], \"section\": \"Increasing diverse role models\", \"text\": \"The I-CA2R2E framework, originally developed to support medical students in their PIF, outlines strategies such as fostering individual connections, acknowledging students\\u2019 experiences, adjusting education to be more inclusive, and role modeling [41]. One study noted the framework\\u2019s potential for addressing the unique challenges faced by URiM students [29]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR30\", \"CR30\"], \"section\": \"Increasing diverse role models\", \"text\": \"Studies additionally suggest that minoritized professionals should have more access to leadership positions within academic medicine [30]. Compared to their non-URiM counterparts, URiM faculty members express greater aspirations for leadership in academic medicine; however, they experience lower levels of inclusion, trust, and relationships within the academic environment. To address the leadership aspirations of URiM physicians, it is crucial to focus on the leadership ambitions of this group. These leadership opportunities should encompass positions at the institutional level [30]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR42\", \"CR42\", \"CR43\"], \"section\": \"Sharing narratives of lived experiences\", \"text\": \"Another proposed intervention in medical education is to make room to share lived experience narratives with students. Banks\\u2019s theory of multicultural education highlights the positive significance of integrating a curriculum that reflects the lived experiences of minoritized individuals and is grounded in equity pedagogy [42]. In the educational context, narratives based on lived experiences can be leveraged to deepen understanding, cultivate empathy, and enhance cultural competence [42]. One suggested intervention in medical education includes incorporating a professionalism module focused on sharing experiential narratives into the curriculum [43]. In this module, physicians, including those from underrepresented groups, can be invited to recount career-defining moments that necessitated reconciling personal and professional identities. The presence of URiM physicians could contribute to a heightened sense of belonging and an increased sense of representation for URiM students.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR44\"], \"section\": \"Elevating awareness about socialization\", \"text\": \"Studies indicate that the socialization process in medical education can create pressure for URiM students to assimilate into the dominant culture, which may conflict with their existing values and beliefs [44]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR44\", \"CR44\", \"CR45\"], \"section\": \"Elevating awareness about socialization\", \"text\": \"Research also highlights that PIF is influenced by values and ontological systems cultivated during childhood, suggesting that students should be given more time to reflect on their diverse perspectives and backgrounds during their medical training [44]. Faculty-student interactions, such as small-group sessions or one-on-one meetings, are identified as opportunities to better understand students\\u2019 values, beliefs, and practices shaped by their upbringing and communities [44, 45]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR44\", \"CR44\", \"CR46\"], \"section\": \"Discussing privilege and underprivilege in medical education\", \"text\": \"Moreover, studies emphasize the importance of addressing socioeconomic experiences, privilege, and underprivilege in medical education to address disparities among medical students [44]. Doing so can contribute to an environment where medical students from underprivileged backgrounds feel more easily seen and understood by their peers and educators. Additionally, it broadens medical students\\u2019 understanding of patients from disadvantaged backgrounds, which could shape their PIF. To facilitate discussions on sensitive topics such as socioeconomic experiences and privilege, educators are encouraged to create a safe space for medical students to engage in these conversations. This involves remaining attentive to inadvertent microaggressions that may arise during these discussions [44, 46]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR21\", \"CR21\", \"CR21\"], \"section\": \"Fostering identity safety\", \"text\": \"Lastly, it is also acknowledged that minoritized individuals play an active role in cultivating a sense of identity safety for themselves by addressing the challenges that they face [21]. Minoritized individuals contribute proactively to their psychological and educational well-being. They engage in behaviors such as seeking mentors with similar identities, engaging with leadership for accommodations, and fostering a sense of belonging, all of which contribute to this proactive sense of safety [21]. Additionally, studies highlight the positive impact of diverse identities, which are viewed not only as challenges but as assets that enhance patient care through effective communication and unique perspectives [21]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"Tab1\", \"CR2\", \"CR30\", \"CR31\", \"CR39\", \"CR43\", \"CR45\"], \"section\": \"Fostering identity safety\", \"text\": \"Out of the 22 articles included in this study, only six presented concrete approaches to address the challenges faced in PIF. Table\\u00a01 provides a comprehensive overview of these articles, summarizing key interventions proposed in the literature to address challenges in PIF for URiM groups [2, 30, 31, 39, 43, 45]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR47\", \"CR3\", \"CR2\", \"CR35\"], \"section\": \"Normative practices and the norm group\", \"text\": \"Normative practices refer to established customs, behaviors, or procedures within an institution that reflect dominant cultural norms or values [47]. Historically, normative practices in medical schools included segregationist policies that excluded Blacks/African Americans from medical education [3]. Contemporary normative practices within medical schools may encompass the belief that norms of medical professionalism are deeply rooted in the historical and Eurocentric portrayal of a physician, leading to instances where URiM groups report being scrutinized or singled out based on their cultural or ethnic attributes [2, 35]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR48\", \"CR48\"], \"section\": \"Normative practices and the norm group\", \"text\": \"The norm group comprises individuals who adhere to the dominant cultural norms or values within a given context. For example, medical students in Dutch medical schools are disproportionately likely to have parents with a very high income [48]. In 2020, 56.3% of first-year medical students had at least one parent within the top 10% highest-income earners in the Netherlands. This shows that the norm group among Dutch medical students primarily consists of individuals from higher socioeconomic backgrounds [48]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR42\", \"CR43\"], \"section\": \"Interventions for norm group and minoritized groups\", \"text\": \"Several interventions identified in this study targeted both the norm group and minoritized groups. For instance, adapting medical curricula to incorporate diverse narratives, including sharing the lived experiences of minoritized individuals, benefits both URiM students and students from the norm group [42, 43]. By introducing diverse narratives into the curriculum, this approach disrupts existing normative practices that may perpetuate exclusivity and bias.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR44\", \"CR29\", \"CR41\"], \"section\": \"Interventions for norm group and minoritized groups\", \"text\": \"Additionally, some interventions focus on educating medical educators about the socialization process in medical education. Studies indicate that this process can create pressure for URiM students to assimilate into the dominant culture, which may conflict with their existing values and beliefs [44]. By promoting awareness of this socialization process, educators can help students navigate the tension between their cultural identity and the expectations of the medical profession. In doing so, these interventions seek to disrupt normative practices that perpetuate a singular, often homogeneous view of the medical profession. The I-CA2R2E framework addresses normative practices, the needs of minoritized groups, as well as the norm group [29, 41]. By encouraging self-awareness and reflection among faculty members, it challenges existing norms. Simultaneously, it could provide essential role models for URiM students, enhancing their sense of belonging. Additionally, it fosters individual connections and open exchanges, creating supportive relationships that directly benefit minoritized individuals in predominantly White institutions.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR21\", \"CR30\"], \"section\": \"Interventions that primarily focus on minoritized groups\", \"text\": \"Fostering identity safety tends to focus primarily on individuals from minoritized groups. This intervention suggests that URiM individuals should actively contribute to their well-being by seeking mentors with similar identities, engaging with leadership for support, and fostering a sense of belonging, which can enhance their identity safety [21]. Another intervention focuses on the recruitment and leadership opportunities for URiM faculty. Actively recruiting URiM faculty and providing access to leadership positions can make medical schools a more inclusive environment [30]. This approach focuses on supporting minoritized groups by providing resources to them specifically, rather than addressing normative practices. However, it is noted that recruitment alone may not be sufficient to bring about lasting changes in normative practices, and broader strategies targeting institutional policies and culture may be needed for enduring impact.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR29\", \"CR28\", \"CR28\", \"CR30\", \"CR32\"], \"section\": \"Lack of role models and minority tax\", \"text\": \"Insufficient role models and mentorship remain a challenge for URiM groups, who often express\\u00a0a longing for mentors with similar identities [29]. This need for role models is strongly felt by\\u00a0Dutch URiM students as well [28]. Dutch URiM alumni have expressed that having more\\u00a0doctors from minority backgrounds would have been beneficial for them [28]. Many URiM\\u00a0professionals engage in racial uplift by taking on mentoring roles to support others and give back\\u00a0to their communities [30]. Additionally, they experience the burden of the \\u2018minority tax\\u2019 [32].\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR20\", \"CR20\", \"CR20\", \"CR33\"], \"section\": \"Microaggressions\", \"text\": \"Microaggressions remain a pervasive challenge for URiM students with reports of discriminatory interactions involving peers, faculty, and patients [2, 20]. Many students describe heightened visibility due to their racial or ethnic identity, often encountering discriminatory experiences such as patients refusing care based on racial bias [20]. This heightened scrutiny exacerbates the pressure to perform exceptionally, as URiM students feel pressured to demonstrate their competence more than their White counterparts [20]. Such persistent pressure can adversely impact the academic and professional success of URiM students [33]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR49\", \"CR50\"], \"section\": \"Microaggressions\", \"text\": \"In the Netherlands, similar patterns emerge among Dutch URiM students. Many report feeling discriminated against based on their ethnic, cultural, and/or religious identity, particularly in specific parts of the curriculum such as group discussions on biases, case studies, and practical training sessions [49]. In these situations, Dutch URiM students often remain quiet to avoid further scrutiny [50]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR50\", \"CR50\"], \"section\": \"Microaggressions\", \"text\": \"Moreover, a qualitative interview study of female Muslim medical students in the Netherlands reported that certain characteristics, such as wearing a headscarf or speaking with a foreign accent, were associated with being perceived as \\u2018different\\u2019 and contributed to feelings of exclusion [50]. Respondents reported microaggressions, like being told they couldn\\u2019t be \\u2018neutral\\u2019 because of their headscarf [50]. Such tensions underscore the challenges URiM students face in reconciling their personal and professional identities in a medical environment.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR34\", \"CR35\", \"CR35\", \"CR35\", \"CR37\", \"CR51\"], \"section\": \"Pressure to assimilate into the majority culture\", \"text\": \"Studies report that URiM groups face substantial pressure to assimilate into the majority culture to align with Eurocentric standards of professionalism [34, 35]. This is evident in behaviors such as suppressing emotional expressions to avoid conforming to racial stereotypes, such as the \\u201cangry Black woman\\u201d [35]. Furthermore, some Black students strategically alter their appearance, including using ring lights to present a lighter complexion during residency interviews, underscoring the pervasive effects of colorism [35, 37, 51]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR38\"], \"section\": \"Pressure to assimilate into the majority culture\", \"text\": \"Professional appearance norms further perpetuate stereotype threats, as seen in white coat ceremonies where directives on ethnic hairstyles, such as keeping them \\u201cneat,\\u201d implicitly suggest these styles are less professional [2]. These norms reflect societal biases, positioning Eurocentric features as ideal while framing cultural attributes as deviations. This dynamic forces URiM students to navigate \\u201cdouble consciousness,\\u201d balancing their cultural identity with the expectations of the medical profession, complicating their PIF [38]. Although these findings are results related to American medical educational settings, it is possible that Dutch URiM students encounter similar pressures. As a minority in medical environments, they may experience comparable biases and societal expectations regarding professional appearance.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR2\", \"CR31\", \"CR30\", \"CR31\"], \"section\": \"Increasing representation\", \"text\": \"Studies suggest that it is not sufficient for institutions to wait for racially minoritized individuals to express interest in the medical profession. Instead, schools should actively reach out to these communities and invite them into their programs [2]. Although URiM physicians often engage in racial uplift by mentoring URiM students, this responsibility should not rest solely on them [31]. A study recommends that this burden be shared among all medical educators, transitioning from a minority tax to a collective responsibility [30]. To facilitate this shift, academic institutions should implement robust training programs for non-URiM physicians to prepare them for mentoring URiM students [31]. These programs can help mentors understand the sociohistorical context of URiM students, enabling effective support in integrating their racial and professional identities.\"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR44\", \"CR44\", \"CR44\"], \"section\": \"Increasing awareness about socialization\", \"text\": \"Studies indicate that the socialization process in medical education often pressures URiM students to assimilate into the dominant culture, conflicting with their existing values and beliefs [44]. Medical educators should critically reevaluate this process and move away from attempting to mold students into a predetermined image of the \\u201cright kind of doctor\\u201d [44]. Instead, educators should focus on teaching students about their socialization process, acknowledging that PIF is influenced by childhood values and broader ontological systems [44]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR45\"], \"section\": \"Increasing awareness about socialization\", \"text\": \"Additionally, educators should strive to understand students\\u2019 values, beliefs, and practices shaped by their home communities. This can be achieved through explicit conversations about identity construction, clarifying goals, and providing small-group or one-on-one interactions to guide students on their professional journeys [45]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"CR21\", \"CR21\"], \"section\": \"Fostering identity safety\", \"text\": \"Minoritized individuals play an active role in cultivating a sense of identity safety by addressing the challenges they face [21]. They proactively contribute to their psychological and educational well-being by seeking mentors with similar identities and fostering a sense of belonging. Shifting the focus from external factors to individual agency highlights the empowering role of diverse identities in creating a supportive and safe learning environment [21]. \"}, {\"pmc\": \"PMC12746619\", \"pmid\": \"41454317\", \"reference_ids\": [\"Tab2\"], \"section\": \"Further research\", \"text\": \"Finally, a comparative analysis across countries with diverse healthcare and educational systems could identify both universal challenges faced by URiM students and culturally specific solutions. These research directions will help expand our understanding of the factors influencing URiM students\\u2019 PIF and the role that institutional practices and interventions play in shaping their experiences. Table\\u00a02 outlines these recommendations for further exploration.\"}]"

Metadata

"{\"issue-copyright-statement\": \"\\u00a9 BioMed Central Ltd., part of Springer Nature 2025\"}"