‘I sound different, I look different, I am different’: Protecting and promoting the sense of authenticity of ethnically minoritised medical students

Being authentic can improve students' well‐being and enhance the medical student–patient communication and patient safety. However, the underrepresentation of ethnically minoritised students in medical education can result in identity suppression, interfering with students' ability to succeed academically and professionally.


| INTRODUCTION
3][4] The historical exclusion and underrepresentation of ethnically minoritised medical students 5 can result in identity suppression and interfere with students' ability to succeed academically and professionally. 3Furthermore, students' ability to express their true self might be disproportionately affected by societal, structural and institutional factors, such as racism, discrimination and socio-economic inequalities. 6We therefore argue that efforts to promote Equality, Diversity, Inclusion and Belonging (EDIB) need to consider students' sense of authenticity.Such efforts are also needed to minimise the potential risk of psychological harm when students deny or suppress their identity 3,7,8 or, equally, the negative implications of being authentic, different and potentially standing out. 9thenticity is a concept commonly studied in existential psychiatry and philosophy, referring to the degree to which an individual's actions are congruent with their beliefs and desires, despite external pressures. 10In medical education, external pressures include the expectation to adopt a certain personality (e.g., goal-oriented, competitive and high-achiever) or mode of living (e.g., expensive social outings).However, authenticity is about developing self-awareness and encountering external forces. 11When students fail to recognise and/or accept their true intuitions, they can make important decisions influenced by what they think that will please others. 12In contrast, being authentic has been associated with inner growth and maturity, 13 emotional intelligence, mindfulness and self-deceptive enhancement. 14In medical education, authenticity can improve the medical student-patient communication and care, with resultant impacts on patient safety and health outcomes. 15,16is study explores the experiences of ethnically minoritised medical undergraduate students regarding their sense of authenticity within the medical school and strategies that can promote their authenticity.The overarching research questions were as follows: 1. What facilitates and prevents students from being their authentic self during medical school?
2. What learning and teaching strategies can enable students to be or become their authentic self?
To our knowledge, this is one of the first studies to investigate the concept of authenticity in medical students [17][18][19] and the first study focusing on ethnically minoritised medical students.

| METHODS
We adopted a constructivist methodological position considering that our knowledge and understanding was constructed with and through the students.p. 3 Social constructionism has been used widely for the analysis of prejudice and impressions of one's self, 21 which link closely with the conceptual framework of authenticity.
This study was co-designed alongside three medical students from ethnically minoritised communities, who were part of the research team throughout the decision-making process regarding the study design, data collection, analysis and synthesis.Students were also involved in the design of the interview schedule, which is presented in the Supporting Information.We also piloted the interview questions with these students, to ensure that interviews could be completed in-depth within an hour, the questions were relevant and interesting, and to assess whether we have missed any important questions.
The recruitment was advertised through more than 50 students' societies at Imperial College London, such as the Afro-Caribbean, Indian, Bangladeshi, Pakistani, Afghan and Arabic student societies.
Medical students who were interested to participate were signposted to the participant information form and the expression of interest form.Twenty students were purposefully selected to maximise representation across different ethnic groups.Ten of the students identified as 'female', nine as 'male' and one as 'non-binary', all aged between 18 and 24.Students self-identified as Black African (n = 3), and Mixed (n = 2).
The interviews aimed to explore (i) how students perceived their sense of authenticity; (ii) how able they felt to be authentic in the medical school; (iii) barriers and facilitators in the process of achieving self-authenticity; and (iv) strategies that medical schools can take towards promoting students' authenticity.The interviews were conducted by the lead research and lead author (ZM), who was the EDI Lead of the Medical Education Innovation and Research Centre (MEdIC).ZM had an independent position towards the students, and post-interview reflexivity sessions were scheduled with her supervisor (SK), who identifies as ethnically minoritised.
Interviews were analysed through reflexive thematic analysis following the six-step process: familiarisation; coding; generating themes; reviewing themes; defining themes; writing-up. 22This process was undertaken by the lead researcher (ZM), her supervisor (SK), an external expert academic (AZ) and the three medical students who were involved throughout the study.Thematic analysis allowed us to reflect on how our thematic conceptualisation was evolving, growing and deepening alongside increased understanding of students' experiences and perspectives.Tentative findings were also shared with the participants to ensure that we have not misinterpreted their experiences/we have not missed significant insights and to explore the credibility of our findings.
This study gained ethical approval by the Education Ethics Review Panel at Imperial College London (reference number: EERP2021-008a).

| FINDINGS
The findings are divided into three sections: (4th year Nigerian student).
F I G U R E 1 Students' sense of authenticity: barriers, strategies and impact.
Microaggressions, which are often more indirect, subtle or unintentional, led to students being reluctant to express their authentic self, such as wearing clothes that represent them: We were coming back wearing our do-rags and the security guy stopped us and asked for our ID, the only time that has ever happened.We didn't speak about it for ages until a year later and it's funny we both remembered it, which means that we're not imagining these things, they're actually happening (4th year Black African student).
Discrimination was often experienced during placements, particularly by patients who made harmful comments about students: I was with my partners when this man went 'Ugh, there's more of them', referring to the fact that we're a bunch of brown people, it's really hurtful

I sound different, I look different, I am different.
There's a lot of risk when you're authentic, people might not accept you.

| Lack of diversity and representation
Students expressed their disappointment when EDIB sessions were not delivered by people from diverse or underrepresented communities and/or with lived experiences: We had a lecture on racism given by a white lecturer who said she checked it over with a Black colleague.There's no space to be authentic, you're expected to be professional.

| Authenticity and year of study
Authenticity was experienced differently based on students' year of study.First year students were less likely to feel authentic, which was attributed to the transitional phase from high school to higher education and the pressure to develop friendships quickly (e.g., Fresher's week).In contrast, students after their third year appeared more confident in being authentic.This was attributed to their academic pro- With time, I might find the balance between being authentic and professional, but that's a long, long way from now.

| Psychological and emotional impact of authenticity
Students linked authenticity with feelings of happiness, positivity, freedom and comfort.Some also mentioned feeling 'acknowledged', 'valued', 'appreciated', 'fortunate' and 'special'.Sense of belonging was another psychological impact closely linked with authenticity.Students were better able to express themselves in spaces where they felt that they belong, which, in turn, led to higher self-confidence, self-esteem and professional fulfilment.This relationship appeared to be dynamic; the greater the sense of belonging, the more students felt able to express their authentic self: For example, students wanted to be informed about clinical cases that represent the wider society, instead of being taught about how conditions/symptoms appear only on Caucasian people: We had a lecture on appendicitis, and I asked about the pain from appendicitis being experienced differently for people with a certain ethnicity.were going through the questions, and they just skipped mine, got completely ignored.It could have been a mistake, but these instances pile up and then you see a pattern (2nd year mixed-ethnicity student).
Students would also prefer EDIB sessions to be delivered by people with lived experience who had to navigate challenges around expressing their true self and values: If a surgery is long, you can't leave to pray.You want to hear what they did when they were in your shoes (6th year Bangladeshi student).

| Mentoring and personal tutoring
Mentors and personal tutors played a significant role in students' ability to express their authentic self and navigate the resultant challenges, especially when they were also coming from ethnically Having the same mentors or tutors throughout medical school was especially important to build long-term, trusting relationships: I can be more authentic because it's a one-to-one connection that has been built up over years (3rd year Chinese student).

| Zero tolerance policies
Students mentioned how often they hear about zero tolerance policies, yet how rarely the injustices that happen are being addressed.In future policies, students expect recognition that racism and discrimination exist and explicit information about what actions are taken to address them: Knowing that someone will not only look into it but will take you seriously when you report something.
Knowing that something will be done, and it won't be swept under the rug.You want to know that someone's acting on your behalf (5th year Black British student).

| Signposting to complaints procedure
Students expected better signposting to the complaints and reporting procedure, as they expressed that it is unlikely to express their true self in environments where they feel inadequately protected.For

| Culture of transparency
Students highlighted that a culture of transparency needs to be cultivated, where they feel able to have authentic and honest conversations about uncomfortable, challenging or sensitive issues.For example, failure to acknowledge and discuss important issues around not only prevented students from being authentic, but they could also cause harm: A lecturer had a derogatory picture of a black person on the screen.One of my friends was really hurt and emailed him to remove it, and he said, 'I'm leaving next year, it doesn't matter'.It was quite dismissive and not acknowledging that he did something wrong or hurtful (3rd year Pakistani student).
In contrast, when these issues were acknowledged and discussed had the opposite outcome: We had this scandal about some guys being sexist, and when it came out, the head of medical school came to talk to us and reassured us that the medical school does recognise these sorts of things (2nd year Bangladeshi student).
Students mentioned how important it is for the medical school to provide training on how to navigate difficult conversations, either with other students, staff, clinicians or their patients: There is a way to raise concerns, but there isn't advice on how to gently bring things up (1st year mixed-ethnicity student).
There is a way to raise concerns, but there isn't advice on how to gently bring things up.

| Representation and role modelling
Finally, students discussed the importance of representation and role modelling.For example, a student fondly remembered praying with their personal tutor who was also Muslim, which made them feel 'visible'.Another student mentioned that: This study aimed to explore the experiences of ethnically minoritised medical undergraduate students regarding their sense of authenticity within the medical school.Our findings discuss the psychological and emotional impact of being (or not being) authentic, the barriers to being authentic and the pedagogical strategies that medical schools can implement to promote students' authenticity.These findings are also presented visually in Figure 1.
Previous experiences of racism, discrimination and microaggressions were the primary barrier to students' authenticity.Such experiences led to fear of being discriminated again, preventing students from expressing their true self.Most examples came from students' clinical placements with patients who made discriminatory comments about their race or ethnicity.The lack of diversity and representation in leadership positions also hindered students' sense of and belonging.4][25][26] For example, they often had to change their accent or external appearance to fit in.This should be taken into consideration in critical medical education concepts, such as professional identity formation and socialisation. 24is study focuses on six student-led strategies that medical schools can implement to promote authenticity.Strategy one suggests that EDIB sessions should be delivered by facilitators with lived experience to support students navigate and understand challenging experiences around expressing their authentic self.EDIB principles should also be spiralled throughout the curriculum to reflect the EDI framework, which highlights that diversity must be at the core and not at the periphery of medical education. 27udents found the zero tolerance policies were insufficiently implemented, and they expected medical school leaders to take stronger action against racism/discrimination.Crucially, students needed better signposting to the complaints procedure and well-being services from the beginning of their academic journey.Most students were not aware how to report instances of racism/discrimination and how to access well-being support.This is a problem commonly reported in studies showing that medical schools are poor at recording students' complaints of racial harassment. 28Yet, evidence shows that students who do not disclose experiences of racism/discrimination are more likely to develop psychological distress, mood and anxiety disorders due to suppression and therefore needs to be taken seriously. 29,30The role of mentors and personal tutors may be invaluable in signposting students to the reporting procedures and wellbeing services and in guiding them to navigate the impact on their personal and professional identity.The benefits appeared to be higher when students remained with the same mentor/tutor throughout the medical school and when they had shared experiences or similar backgrounds (e.g., working-class background and ethnically minoritised).
Students suggested that medical school should provide student training on how to navigate difficult conversations.This echoes studies that found that education does not teach students how to deal with challenging situations, such as discrimination. 1This training would be particularly important for dealing with microaggressions, such as 'jokes' or derogatory language.As microaggressions are one of the main ways that racism is reproduced, students should be trained in how to recognise and address them, whether they are the target or not.Students' desire for honest conversations also links to 'relational authenticity', 31 which places the value of openness and honesty in interpersonal interactions at the core of authenticity. 32e last strategy focused on the importance of representation and role modelling.Prince et al. 33 argue that the underrepresentation of ethnic minorities in academic medicine is partially because students lack role models they can identify with.Considering that role models can motivate, inspire and instil professional behaviours, 34 role models in positions of power can significantly affect students' ability to be authentic.This has been explained by theories of racial similarity and shared experience of oppression, 35 which makes students more likely to be authentic around staff with perceived shared experiences.
In terms of the psychological and emotional impact of authenticity, our findings echo literature associating authenticity with higher self-awareness, optimism, well-being and belonging. 12Because of the dynamic relationship between authenticity and belonging, students experienced higher sense of belonging in environments where they could be authentic; and vice versa, greater sense of belonging enabled students to be more authentic.p. 386 Therefore, we argue that medical schools need to create the conditions and safe environments where students feel comfortable to express their authentic self, rather than reproducing oppression and identity suppression.This means integrating authenticity as important element in pedagogical strategies and spending more time on discussing issues of authenticity in class.
This is one of the first studies to investigate the concept of authenticity in medical students and to our knowledge, the first study with a clear focus on medical students from ethnically minoritised communities.Considering the wide use of the term 'authenticity', however, it is possible that relevant studies exist in other fields.While previous studies on authenticity focussed on 'feeling like a doctor', 17 professional identity 18 and student metis, 19 our study shows the specific barriers to being authentic faced by ethnically minoritised medical students and suggestions on how to mitigate these barriers coming from students themselves.However, one of the limitations of this study is that it was conducted with a relatively small number of students in a specific higher education institution; therefore, the generalisability of the findings is limited.Future studies could focus on other students' backgrounds or on staff from ethnically minoritised communities to see if experiences are mirrored.Future studies could also benefit from a larger perspective, by including student groups from other universities and countries.Finally, future research could investigate how the implementation of the above student-led strategies in medical schools may create safer and more inclusive learning

(
4th year Pakistani student).Such experiences led to fear of being discriminated again if students expressed their true self: I'm applying for jobs thinking, would they assume I didn't study in England because I don't sound like my British counterparts?Would they think I'm less clinically adequate?I sound different, I look different, I am different.There's a lot of risk when you're authentic, people might not accept you.Whereas if I'm in my code, switched personality, people accept it.But I know deep down, that's not me (6th year Nigerian student).

3. 1 . 3 |
Culture in medicineWithin the medical culture, authenticity was often perceived as opposite to professionalism:There's no space to be authentic, you're expected to be professional … dress in a certain way, take off jewellery, don't have tattoos … (4th year Pakistani student).
Due to the strong hierarchical structure, students argued that only people in positions of power have the privilege to be authentic: You go from medical student to junior doctor, then up the ladder until you're consultant.I'm at the bottom of the hierarchy.I'd imagine, as I become more senior, I'd be more comfortable sharing who I am (3rd year Arab student).Authenticity was also hindered by the competitive nature of medicine: Everyone is doing everything all the time and accelerating … I don't understand how well you can do all these things?It's like you're never enough because everyone got a massive CV, in their LinkedIn profiles are completely different people (4th year Arab student).
gress and development of safer relationships: Everyone goes 'first year is the easiest, first year you can chill'.I was like, no, I constantly feel too dumb for this university.But now I'm 100% part of this, I made it, people recognise my name … (3rd year Pakistani medical student).Hence, authenticity was perceived as a 'privilege that comes a bit later' (5th year Chinese student):With time, I might find the perfect balance between being authentic and professional, but that's a long, long way from now (2nd year mixed-ethnicity student).

I
'm a lot happier and positive, even when I'm completely vulnerable about my identity.You create stronger relationships which is a never-ending cycle.All of a sudden, they know you in a deeper way and you feel safer to present that [vulnerable] side of yourself (4th year Nigerian student).In contrast, lack of authenticity was associated with feelings of shame, anxiety, depression, frustration, anger, withdrawal, sadness, helplessness and exhaustion.As a student said: I look back and regret not being myself.I was ashamed I didn't embrace my Pakistani roots, or my Muslim roots.I was ashamed for not being myself (4th year Pakistani student).
minoritised backgrounds: I don't know how she [tutor] picked up that I wasn't feeling well.She's the first person I ever told about domestic violence.She encouraged me to go counselling and that was a catalyst to become more accepting of who I am and explore why I am who I am.It helped me not wanting to ignore those parts of my life and bury them (2nd year Bangladeshi student).
Students argued that training on having authentic conversations could also lead to better student-patient relationship and patient care: Your patient should know who you are, your beliefs.If you're getting to know someone well, they have the right to know you too.Normally the attitude is to remove the individual, you're just the doctor.Whereas it's way better when you have a personal connection and create a partnership, rather than just a duty (2nd year mixed-ethnicity student).
would love to have role models of doctors who are