Racial and Ethnic Discrimination and Medical Students' Identity Formation.

Importance: Investigating racial and ethnic discrimination in medical education is crucial for addressing disparities and fostering an inclusive environment. Objective: To assess how racial and ethnic discrimination in medical school is associated with personal and professional identity formation (PPIF) by race and ethnicity. Design, Setting, and Participants: This retrospective cross-sectional study used deidentified data on 37 610 medical students who matriculated in 2014 or 2015 and took the Association of American Medical Colleges Graduation Questionnaire (GQ) between 2016 and 2020. Statistical analysis was performed from September 1 to November 20, 2023. Exposures: Experiences of racial and ethnic discrimination were assessed through responses to 3 GQ questions about denial of opportunities, offensive remarks or names, and lower evaluations or grades due to race or ethnicity. Main Outcomes and Measures: Personal and professional development were measured as 2 separate outcomes using 2 GQ statements rated on a 5-point Likert scale (where 1 indicated strongly disagree and 5 indicated strongly agree): "My medical school has done a good job fostering and nurturing my development as a person" and "My medical school has done a good job fostering and nurturing my development as a physician." Variables of personal and professional development were both dichotomized. Results: Of 37 610 medical students, 18 200 (48.4%) were female, and 19 410 (51.6%) were male; 2458 (6.5%) were African American or Black, 7801 (20.7%) were Asian, 2430 (6.5%) were Hispanic, 21 380 (56.9%) were White, 2404 (6.4%) were multiracial, and 1137 (3%) were other race or ethnicity. Most respondents attested that their medical school fostered their personal (27 272 [72.5%]) and professional (34 560 [91.9%]) development. African American or Black students reported the lowest rates of personal (1603 of 2458 [65.2%]) and professional (2182 of 2458 [88.8%]) development, and experienced lower likelihoods of personal (adjusted risk ratio [ARR], 0.89 [95% CI, 0.86-0.93]) and professional (ARR, 0.95 [95% CI, 0.94-0.97]) development than White students. Racial discrimination was inversely associated with development, with the highest PPIF rates among those never experiencing discrimination (personal, 25 089 of 33 508 [74.9%]; and professional, 31 257 of 33 508 [93.3%]). Those experiencing isolated discrimination (personal: ARR, 0.83 [95% CI, 0.80-0.87]; professional: ARR, 0.92 [95% CI, 0.91-0.95]) and recurrent discrimination (personal: ARR, 0.63 [95% CI, 0.60-0.66]; professional: ARR, 0.82 [95% CI, 0.80-0.84]) had relatively lower likelihoods of PPIF. African American or Black students experienced the highest rate of recurrent discrimination (543 of 2458 [22.1%]). No significant PPIF risk differences were found for other racial and ethnic groups underrepresented in medicine without discrimination compared with White students without discrimination, but all groups with recurrent discrimination had relatively lower PPIF risk. Conclusions and Relevance: In this cross-sectional study of US medical students, racial and ethnic discrimination was associated with lower PPIF across all racial and ethnic groups compared with White students without such experiences. African American or Black students disproportionately faced this discrimination. Systemic changes in medical education are needed to combat discrimination and ensure equity in holistic student development.

Race and Sex Disparities Among Emergency Medicine Chief Residents.

Importance: Physicians who belong to minoritized racial and ethnic groups remain underrepresented and underpromoted. Serving as a chief resident is an important position of leadership and prestige, and indicates a benchmark for future professional success. However, it is unknown if disparities in race and/or sex exist in the chief resident selection process. Objective: To describe race, ethnicity, and sex of emergency medicine (EM) chief residents and determine the association of racial identity and the intersectionality of race and sex for selecting chief residents in US emergency medicine departments. Design, Setting, and Participants: This cohort study analyzed data collected from the Association of American Medical Colleges and the Electronic Residency Application Service in the graduating classes of 2017 and 2018. Data were analyzed between December 2021 and January 2023. Main Outcomes and Measures: Relative risk (RR) of selection for chief residency for Black, Asian, and Hispanic EM residents in comparison with White counterparts. Results: Among 3408 studied residents, 738 (21.7%) served as chief resident (2253 male [66.1%]; 451 Asian [13.2%], 144 Black [4.2%], 158 Hispanic [4.6%], 239 more than 1 race [7.0%], 46 other [1.3%], and 2370 White [69.5%]). Of chiefs, 81 (11.0%) identified as Asian, 17 (2.3%) as Black, and 26 (3.5%) Hispanic. Asian residents were 78% (95% CI, 63%-96%) as likely to be promoted to chief resident compared with White peers, and Black residents were 51% (95% CI, 32%-80%) as likely as White residents. In our fully adjusted model, racial differences remained significant for Black residents, who were half as likely as white residents to be selected for chief residency (adjusted risk ratio [aRR], 0.55; 95% CI, 0.36-0.82). Overall, White women were most likely to be selected for chief residency and 20% more likely to be selected than White men counterparts (aRR, 1.20; 95% CI, 1.03-1.39). In comparison, women underrepresented in medicine (a category that included residents identified as Black, Hispanic, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander) were least likely to be selected for chief promotion, and 50% as likely to be selected for chief resident compared with White men (aRR, 0.50; 95% CI, 0.06-0.66). Conclusions and Relevance: In this 2024 nationally representative study of EM residents, chief promotion was lower among residents identifying as Asian or Black, and in particular, women underrepresented in medicine. This study's findings suggest further review of chief resident selection process by residency programs and accreditation bodies is needed to ensure workforce equity for promotion and opportunities for leadership.

LGBTQ+ individuals are not explicitly represented in emergency medicine simulation curricula.

Background: Medical educational societies have emphasized the inclusion of marginalized populations, including the lesbian, gay, bisexual, transgender and queer (LGBTQ+) population, in educational curricula. Lack of inclusion can contribute to health inequality and mistreatment due to unconscious bias. Little didactic time is spent on the care of LGBTQ+ individuals in emergency medicine (EM) curricula. Simulation based medical education can be a helpful pedagogy in teaching cross-cultural care and communication skills. In this study, we sought to determine the representation of the LGBTQ+ population in EM simulation curricula. We also sought to determine if representations of the LGBTQ+ population depicted stigmatized behavior. Methods: We reviewed 971 scenarios from six simulation case banks for LGBTQ+ representation. Frequency distributions were determined for major demographic variables. Chi-Squared or Fisher's Exact Test, depending on the cell counts, were used to determine if relationships existed between LGBTQ+ representation and bank type, author type, and stigmatized behavior. Results: Of the 971 scenarios reviewed, eight (0.82%) scenarios explicitly represented LGBTQ+ patients, 319 (32.85%) represented heterosexual patients, and the remaining 644 (66.32%) did not specify these patient characteristics. All cases representing LGBTQ+ patients were found in institutional case banks. Three of the eight cases depicted stigmatized behavior. Conclusions: LGBTQ+ individuals are not typically explicitly represented in EM simulation curricula. LGBTQ+ individuals should be more explicitly represented to reduce stigma, allow EM trainees to practice using gender affirming language, address health conditions affecting the LGBTQ+ population, and address possible bias when treating LGBTQ+ patients.

Letters of Reference in the Current Era.

ABSTRACT: Letters of reference (LORs) are a common component of the application process for residency training programs. With the United States Medical Licensing Examination Step 1 transitioning to pass/fail grading and with the increasing use of holistic review, the potential role of LORs is rising in importance. Among some key benefits are the ability to provide a broader and more holistic view of applicants, which can include highlighting elements of experiences or skills that could be missed in their application, as well as providing a third-party assessment of the applicant external to their rotation experiences. However, LORs also face issues, including variation in quality, challenges with comparability, and risk of bias. In this article, the authors discuss the unique benefits, limitations, and best practice recommendations for LORs in academic medicine. The authors also discuss future directions, including the role of artificial intelligence, unblinded, and co-created LORs.

Outcomes of the Main Residency Match for Applicants With Disability.

This cohort study assesses match rates of US applicants with and without disability into specialty residence programs.

Leave of Absence and Medical Student Placement Into Graduate Medical Education by Race and Ethnicity.

This study examines the association between taking a leave of absence from medical school and placement into graduate medical education (GME) by race and ethnicity.

Socioeconomic Diversity in Admissions to MD-PhD Programs, 2014-2019.

This cohort study of applicants to US MD-PhD programs examines the association of application outcomes with family income.

Development of a Tool to Measure Student Perceptions of Equity and Inclusion in Medical Schools.

Importance: Creating an inclusive and equitable learning environment is a national priority. Nevertheless, data reflecting medical students' perception of the climate of equity and inclusion are limited. Objective: To develop and validate an instrument to measure students' perceptions of the climate of equity and inclusion in medical school using data collected annually by the Association of American Medical Colleges (AAMC). Design, Setting, and Participants: The Promoting Diversity, Group Inclusion, and Equity tool was developed in 3 stages. A Delphi panel of 9 members identified survey items from preexisting AAMC data sources. Exploratory and confirmatory factor analysis was performed on student responses to AAMC surveys to construct the tool, which underwent rigorous psychometric validation. Participants were undergraduate medical students at Liaison Committee on Medical Education-accredited medical schools in the US who completed the 2015 to 2019 AAMC Year 2 Questionnaire (Y2Q), the administrations of 2016 to 2020 AAMC Graduation Questionnaire (GQ), or both. Data were analyzed from August 2020 to November 2023. Exposures: Student race and ethnicity, sex, sexual orientation, and socioeconomic status. Main Outcomes and Measures: Development and psychometric validation of the tool, including construct validity, internal consistency, and criterion validity. Results: Delphi panel members identified 146 survey items from the Y2Q and GQ reflecting students' perception of the climate of equity and inclusion, and responses to these survey items were obtained from 54 906 students for the Y2Q cohort (median [IQR] age, 24 [23-26] years; 29 208 [52.75%] were female, 11 389 [20.57%] were Asian, 4089 [7.39%] were multiracial, and 33 373 [60.28%] were White) and 61 998 for the GQ cohort (median [IQR] age, 27 [26-28] years; 30 793 [49.67%] were female, 13 049 [21.05%] were Asian, 4136 [6.67%] were multiracial, and 38 215 [61.64%] were White). Exploratory and confirmatory factor analyses of student responses identified 8 factors for the Y2Q model (faculty role modeling; student empowerment; student fellowship; cultural humility; faculty support for students; fostering a collaborative and safe environment; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation) and 5 factors for the GQ model (faculty role modeling; student empowerment; faculty support for students; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation). Confirmatory factor analysis indicated acceptable model fit (root mean square error of approximation of 0.05 [Y2Q] and 0.06 [GQ] and comparative fit indices of 0.95 [Y2Q] and 0.94 [GQ]). Cronbach α for individual factors demonstrated internal consistency ranging from 0.69 to 0.92 (Y2Q) and 0.76 to 0.95 (GQ). Conclusions and Relevance: This study found that the new tool is a reliable and psychometrically valid measure of medical students' perceptions of equity and inclusion in the learning environment.

Medical Student Burnout by Race, Ethnicity, and Multiple Disability Status.

This cohort study examines the prevalence of burnout among students underrepresented in medicine by race and ethnicity with multiple disability types.

Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity With Sustained and Cultivated Careers in Surgery.

OBJECTIVE: Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS: This retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS: Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery [adjusted relative risk (aRR): 0.92 (0.85-0.98)], while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates. CONCLUSIONS AND RELEVANCE: This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.

Examining trends in emergency medicine journals' publications about racism.

OBJECTIVE: In recent years, the academic medicine community has produced numerous statements and calls to action condemning racism. Though health equity work examining health disparities has expanded, few studies specifically name racism as an operational construct. As emergency departments serve a high proportion of patients with social and economic disadvantage rooted in structural racism, it is critically important that racism be a focus of our academic discourse. This study examines the frequency at which four prominent emergency medicine journals, Annals of Emergency Medicine, Academic Emergency Medicine, the American Journal of Emergency Medicine, and the Western Journal of Emergency Medicine, publish on health disparities and racism. METHODS: This is a descriptive analysis measuring the frequency of publications on health disparities and racism in U.S.-based emergency medicine journals from 2014 to 2021. The search strategies for the concepts of "racism" and "health disparities" used a combination of MeSH and keywords. These search strategies were developed based on prior literature and the MEDLINE/PubMed Health Disparities and Minority Health Search Strategy. Articles identified through the PubMed search were then reviewed by two authors for final inclusion. RESULTS: Since 2014, a total of 6248 articles were published by the four emergency medicine journals over the 8-year study period. Of those, 82 research papers that focused on health disparities were identified and only 16 that focused on racism. Most emergency medicine publications on racism and health disparities were in 2021. CONCLUSIONS: Our findings suggest that the national discourse on racism and calls to action within emergency medicine were followed by an increase in publications on health disparities and racism. Continued investigation is needed to evaluate these trends moving forward.

Promising Practices in US Sponsoring Institutions to Advance Diversity, Equity, and Inclusion in Graduate Medical Education.

Background Best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood. The Accreditation Council for Graduate Medical Education launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion award for sponsoring institutions to celebrate efforts to improve DEI in graduate medical education (GME). Objective To identify themes in practices used by award applicants to improve DEI efforts at their institutions, using a qualitative design. Methods This qualitative study employed an exploratory, inductive approach and constant comparative method to analyze award applications from 2 submission cycles (2020, 2021). Data analysis involved the use of a preliminary codebook of 29 program applications used in a previous study, which was modified and expanded, to perform a subsequent analysis of 12 sponsoring institution applications. Seven adjudication sessions were conducted to ensure coding consistency and resolve disagreements, resulting in the identification of final themes. Results Institutions' approaches to advancing DEI resulted from work within 5 themes and 10 subthemes. The themes encompassed organizational commitment (policies that reflect DEI mission), data infrastructure (tracking recruitment, retention, and inclusion efforts), community connection (service-learning opportunities), diverse team engagement (coproduction with residents), and systematic strategies for DEI support throughout the educational continuum. Consistent across themes was the importance of collaboration, avoiding silos, and the need for a comprehensive longitudinal approach to DEI to achieve a diverse GME workforce. Conclusions This qualitative study identified 5 themes that can inform and guide sponsoring institutions in promoting DEI.

Challenges Facing First-Generation College Graduates in Medical School: A Qualitative Analysis.

Importance: First-generation (FG) medical students remain underrepresented in medicine despite ongoing national efforts to increase diversity; understanding the challenges faced by this student population is essential to building holistic policies, practices, and learning environments that promote professional actualization. Although FG students have been extensively studied in the undergraduate literature, there is little research investigating how FG students experience medical education or opportunities for educators to intervene. Objective: To explore challenges that FG students experience in undergraduate medical education and identify opportunities to improve foundational FG support. Design, Setting, and Participants: This qualitative study was conducted using an online platform with 37 FG students enrolled in 27 US medical schools. An interprofessional team of medical educators and trainees conducted semistructured interviews from November 2021 through April 2022. Participants were recruited using a medical student listserv. Data were analyzed from April to November 2022. Main Outcomes and Measures: After conducting a preliminary analysis using open coding, a codebook was created and used in a thematic analysis; the codebook used a combination of deductive and inductive coding. Results: Among the 37 students recruited for this study, 21 (56.8%) were female; 23 (62.2%) were in the clinical phase of training; 1 (2.7%) was American Indian or Alaska Native, 7 (18.9%) were Hispanic, Latino, or of Spanish origin, 8 (21.6%) were non-Hispanic Asian or Asian American, 9 (24.3%) were non-Hispanic Black or African American, and 23 (32.4%) were non-Hispanic White; mean (SD) age was 27.3 (2.8) years. Participants described 4 major themes: (1) isolation and exclusion related to being a newcomer to medicine; (2) difficulty with access to basic resources (eg, food, rent, transportation) as well as educational (eg, books); (3) overall lack of faculty or institutional support to address these challenges; and (4) a sense of needing to rely on grit and resilience to survive. Conclusions and Relevance: Although grit and resilience are desirable traits, results of this study suggest that FG medical students face increased adversity with inadequate institutional support, which forces them to excessively rely on grit and resilience as survival (rather than educational) strategies. By applying the holistic model often used in admissions to the postmatriculation educational process, targeted and flexible initiatives can be created for FG students so that all students, regardless of background, can achieve robust professional actualization.

Vicarious Racism, Direct Racism, and Mental Health Among Racialized Minority Healthcare Workers.

BACKGROUND: Racism-related stress is a root cause of racial and ethnic disparities in mental health outcomes. An individual may be exposed to racism directly or vicariously by hearing about or observing people of the same racial and/or ethnic group experience racism. Although the healthcare setting is a venue by which healthcare workers experience both direct and vicarious racism, few studies have assessed the associations between direct and vicarious racism and mental health outcomes among healthcare workers. METHODS: In this cross-sectional study, we assessed the relationships between direct and vicarious racism and symptoms of posttraumatic stress, depression, and anxiety among healthcare workers in the USA in 2022. RESULTS: Our sample consisted of 259 healthcare workers identifying as a racialized minority, including 68 (26.3%) who identified as mixed-race, 61 (23.6%) East Asian, 36 (13.9%) Black, 33 (12.7%) South Asian, 22 (8.5%) Southeast Asian, 21 (8.1%) Middle Eastern/North African, and 18 (6.9%) another race. The mean age was 37.9 years (SD 10.1). In multivariable linear regression models that adjusted for demographics, work stressors, and social stressors, we found that increased reporting of vicarious racism was associated with greater symptoms of anxiety (B = 0.066, standard error = 0.034, p = .049). We did not identify significant relationships between vicarious and direct racism and symptoms of posttraumatic stress or depression in the fully adjusted models. CONCLUSIONS: Our findings should be considered by academic health systems to mitigate the negative impact of racism on healthcare workers' mental health.

Experiences with Racism Among Asian American Medical Students.

Importance: Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students. Objective: To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment. Design, Setting, and Participants: This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years. Main Outcomes and Measures: The medical school experiences of Asian American medical students. Results: Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future. Conclusions and Relevance: In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.

Intersectional Disparities in Emergency Medicine Residents' Performance Assessments by Race, Ethnicity, and Sex.

Importance: Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. Objective: To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. Design, Setting, and Participants: This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Exposure: Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Main Outcomes and Measures: Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. Results: The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. Conclusions and Relevance: This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.

Association of Racial and Ethnic Identity With Attrition From MD-PhD Training Programs.

This cohort study analyzes the attrition rates of students from MD-PhD training programs by race and ethnicity.

Transition From Mentored to Independent NIH Funding by Gender and Department.

This study uses National Institutes of Health RePORTER data for mentored K awards and R01-equivalent grants to all departments in US schools of medicine to characterize K-award distribution and K-to-R transition by gender and department between 1997 and 2021.