For more than two decades, medical schools have worked hard to diversify, expanding pipeline programs, scholarships, and recruitment strategies to increase representation among students from historically excluded groups. These efforts have produced measurable gains in medical school enrollment, with the proportion of Black and Latino students increasing over the past decade. And yet, diversity in the physician workforce has remained relatively unchanged. Black and Latino physicians continue to comprise a disproportionately small share of practicing physicians. There is a leak in the pipeline: residency. Residency, a mandatory three- to seven-year apprenticeship, depending on specialty, is the sole gateway to board certification and independent medical practice in the United States. Failure to complete residency is not a temporary detour, but rather, a career-ending event for most people — one that is not uniformly experienced. Unpublished 2015 data from the Accreditation Council for Graduate Medical Education showed that while only 5% of resident physicians are Black, they accounted for 20% of dismissals. Emerging national data reinforce that residency training not only shapes clinicians but also determines who is ultimately allowed to enter the physician workforce. In a national study of more than 1,700 resident physicians that I led, we found that Black trainees were significantly more likely than their non-Black peers to report negative disciplinary experiences — ranging from involvement of program leaders to formal remediation. These disparities persisted even after accounting for gender, specialty type, and socioeconomic factors. At the same time, residents across minoritized groups described disciplinary processes that were often subjective, inconsistently applied, and lacking transparent criteria or due process. A subset of residents I interviewed described being placed on remediation or probation without prior feedback, clear expectations for improvement, or a defined path back to good standing. Others described disciplinary processes that escalated quickly and unpredictably, often tied to subjective assessments of behavior rather than remediable clinical skills. In these accounts — disproportionately shared by Black residents — discipline was not experienced as part of training. It was experienced as a mechanism of exclusion. Residency programs are guided by a set of core competencies intended to standardize assessment across training environments. These competencies include medical knowledge, patient care, communication, and professionalism. Within this context, discipline should function as a tool for education by identifying gaps, providing structured support, and ensuring that trainees meet clearly defined competency standards. But in practice, these domains function less as standardized measures and more as flexible constructs shaped by institutional culture and individual judgment. When high-stakes decisions — such as remediation, probation, or dismissal — are tied to criteria that are not clearly defined or consistently applied, they create space for human bias. But there is a more fundamental question that has received far less attention: Why are residency programs disciplining and dismissing trainees at all in a system explicitly funded to train them? The United States invests nearly $30 billion in public funds annually in graduate medical education, primarily via Medicare. These funds are intended to support the development of a physician workforce capable of meeting the nation’s health needs. Residents unable to complete training not only limits the return on the public investment but perpetuates the physician shortage, which is projected to reach as high as 86,000 physicians by 2036. Yet there is no requirement that programs report completion rates, remediation patterns, or disciplinary outcomes by race or other demographic factors. Nor are there standardized expectations for due process in disciplinary systems. At a moment when diversity, equity, and inclusion efforts are facing increasing political scrutiny, findings of racial disparities in disciplinary actions during residency training are often misinterpreted as failures of affirmative action or individual deficiency, reinforcing the belief that those who struggle in training are less qualified — even though all residents have already met rigorous and standardized criteria of having completed medical school, passed national licensing examinations, and secured positions through a highly competitive national match process. Rather than prompting examination of the systems in which those outcomes occur, a common counterargument is that attention to diversity risks lowering standards or excusing poor performance. But the evidence suggests the opposite problem: Standards may be applied more leniently to trainees who align with dominant group expectations, and more harshly to those who do not. A training system that produces consistent racial disparities in disciplinary outcomes must be examined and corrected, regardless of intent. Several steps consistent with the basic principles of accountability would move the field in this direction: First, federal agencies that fund graduate medical education should require programs to regularly report training outcomes, including who finishes, who gets disciplined, and who gets dismissed, broken down by race and other relevant characteristics. Without measurement, disparities remain invisible. Second, accreditation bodies should establish clearer expectations for how disciplinary processes work, including documentation standards, defined criteria for escalating consequences, regular audits of disciplinary decisions to check for bias, and a meaningful appeals process. Third, residency programs should replace vague behavioral judgments with skill-based improvement plans that give explicit criteria for success. Finally, residents must have safe ways to raise concerns about how they’re being evaluated and disciplined, without fear of retaliation. The physician workforce is not shaped solely by who enters medicine. It is shaped by who is allowed to finish. Unless equitable standards are created and enforced, groups historically excluded will continue to be excluded. Vanessa Grubbs, M.D., MPH, is a board-certified nephrologist and internist; founder and president of Black Doc Village, a nonprofit organization focused on expanding the Black physician workforce; the author of two books, including “Negligent by Design: Anti-Blackness in American Medicine and How to Address It” (North Atlantic Books, 2025); and a member of STAT’s 2023 STATUS List.
