Systematic Review of Barriers Faced by Residents Underrepresented in Medicine: a Donabedian Framework Analysis

Racial and ethnic diversity in the physician workforce is critical for advancing health equity and improving patient care. However, residents of color remain underrepresented and face unique challenges during residency school, which may affect retention and career advancement. To systematically review the literature on the experiences of residents of color in U.S. medical residency programs, with particular attention to structural, process-related, and outcome challenges as described by the Donabedian framework. We conducted a systematic review of four databases (Medline, CINAHL, Academic Search Complete, & APA PsycInfo) for articles published between January 2012 and December 2024. Studies were eligible if they examined challenges faced by residents of color during residency training. A total of 862 records were identified; after screening and eligibility review, 13 studies were included in the final analysis. Thirteen studies (11 empirical, 2 program reviews) were included. Structural barriers included underrepresentation in leadership and insufficient institutional commitment to diversity. Process-related challenges involved inequities in evaluations, and lack of mentorship. Outcomes of these structural and process barriers included reduced well-being, burnout, attrition, stereotype threat, and imposter phenomenon. Residents of color encounter persistent structural, process, and outcome-related challenges that undermine their professional development and contribute to ongoing inequities in the physician workforce. Evidence suggests that sustainable diversity initiatives, structured mentorship, and inclusive learning environments are essential for supporting residents of color and advancing equity in medical education.