Purpose The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. Method The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/ behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. Results Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. Conclusions This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.
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