Characterizing Asian American medical students' experiences with microaggression and the impact on their well-being.

PURPOSE: This mixed-methods study quantified and characterized incidents of microaggressions experienced by Asian American medical students. The authors report on their impact and suggest improvements to create a more equitable and supportive learning environment. METHOD: Quantitative and qualitative data were collected from 305 participants who self-identified as Asian American or Pacific Islander. An online, anonymous survey was sent to US medical students through the Asian Pacific American Medical Student Association (APAMSA). Questions explored incidence, characteristics of, and response to microaggressions. We conducted four focus groups to further characterize students' experiences. Data were organized and coded, and thematic analysis was used to identify core themes. RESULTS: Racial microaggressions were prevalent among Asian American medical students. Nearly 70% (n = 213) of survey respondents reported experiencing at least one incident during their medical training to date. The most common perpetrators were patients (n = 151, 70.9%) and fellow medical students (n = 126, 59.2%), followed by professors (n = 90, 42.3%). The most prevalent themes included being perceived as a perpetual foreigner, the assumption of timidness, and ascription of the model minority myth. Students rarely reported the incident and usually did not respond immediately due to fear of retaliation, uncertainties about the experience or how to respond appropriately, and perception that they would bear the burden of advocacy alone. Experiences with microaggressions led to feelings of frustration and burnout and had a negative impact on mental health. Recommendations were made to improve the anonymous reporting systems in medical schools, and to increase diversity and inclusion in medical education and leadership. CONCLUSIONS: Asian American medical students face high exposure to racial microaggressions during their medical education that adversely impact their mental health. Changes are needed in medical training to create a more equitable and inclusive learning environment.

The Impacts of Engagement in the Latino Medical Student Association.

Importance: The Latino Medical Student Association (LMSA) is a student-run national organization founded in 1972 dedicated to recruiting and retaining members enrolled in health professions programs through academic and social support activities. This study investigates the career impact of member participation in LMSA. Objective: To determine if engagement in LMSA at the individual and school levels contributes to retention, success, and commitment to underserved communities. Design: A voluntary online retrospective 18-question survey sent to LMSA-member medical students in the United States and Puerto Rico from the graduating classes of 2016-2021. Setting: Students in medical schools in the United States and Puerto Rico. Main Outcomes and Measures: There were 18 survey questions. A total of 112 anonymous responses were collected from March 2021 to September 2021. The survey queried levels of engagement with the LMSA and agreement on questions related to support, belonging, and career development. Results: There is a positive relationship between level of engagement in the LMSA and social belonging, peer support, career networking, community engagement, and career commitment to serve Latinx communities. These positive outcomes were enhanced for respondents reporting strong support for their respective school-based LMSA chapters. We did not find a significant relationship between participation in the LMSA and research experiences during medical school. Conclusions and Relevance: Participation in the LMSA is associated with positive individual support and career outcomes for members. Supporting the LMSA as a national organization and within school-based chapters can increase support for Latinx trainees and enhance career outcomes.

Bias Breakers: Continuous Practice for Admissions and Selection Committees.

Introduction: Admissions and selection committees face challenges in identifying and mitigating biases in policies, processes, and discussions. Past bias training has focused on defining bias and presenting the negative impact of bias for committees. Methods: This interactive training used committee comments, reflection, and audience response to enhance the contextual recognition of bias in admissions and selection processes and practices. For each bias type, we presented specific mitigation strategies and examples. The workshop was offered at four medical schools between December 2020 and April 2021. Participants were committee members (n = 126), largely medical school faculty, involved in MD, MD/PhD, and residency program selection at participating schools. A paired pre- and postworkshop assessment was conducted for each session to determine effectiveness of the workshop. Results: Mean scores for each of the postassessment items ranged from 4.0 to 4.2 and were statistically significantly different from the preassessment scores per respective item. The results of a paired two-way t test found that these pre- to postworkshop assessment score increases were statistically significant across all assessment questions (ps < .001). Participants reported in their comments that the workshop was effective in establishing a safe and judgment-free learning environment to explore and identify biases and build skills and confidence for mitigating them. Discussion: Interactive and applied bias training can be an effective strategy to advance committee culture and practice in recognizing and mitigating bias. This workshop provides committees with ongoing tools for equity practice in selection and decision-making.

Deferred Action for Childhood Arrivals (DACA): Maximizing Impacts in Medical Education and Health Care.

Introduction: Deferred Action for Childhood Arrivals (DACA) provides a path for individuals who are undocumented to join the physician workforce. Indeed, recipients of DACA can play an important role in addressing health inequities in medicine. Although DACA has been in place since 2012, many medical schools remain unaware of it or are hesitant to consider recipients for admission. In a similar vein, the premedical community, including those with DACA status, may be unaware of their eligibility and the steps necessary to pursue medicine. Further education and outreach are needed to achieve institutional policies conducive to the inclusion and success of those undocumented in medicine. Methods: We created an hour-long workshop to empower learners with key knowledge relevant to DACA policy and its impact on medicine. We evaluated the workshop through pre- and postworkshop questionnaires assessing participant knowledge and attitudes based on the theory of planned behavior (TPB). Results: A total of 112 participants engaged in our workshop. Ninety-one pretests and 61 posttests were completed by attendees. Data revealed a significant increase in performance on all knowledge-based and TPB questions, including intention to participate in future policy development. Moreover, participants reported appreciating the interactive nature of the session and expressed feelings of empowerment by their newfound knowledge base. Discussion: This workshop provides a promising foundation from which conversations and progress regarding DACA-related medical education policy can begin. Specifically, the workshop engages participants in the process of identifying actionable steps for overcoming barriers to inclusion and support.

First-generation and continuing-generation college graduates' application, acceptance, and matriculation to U.S. medical schools: a national cohort study.

Many U.S. medical schools conduct holistic review of applicants to enhance the socioeconomic and experiential diversity of the physician workforce. The authors examined the role of first-generation college-graduate status on U.S. medical school application, acceptance, and matriculation, hypothesizing that first-generation (vs. continuing-generation) college graduates would be less likely to apply and gain acceptance to medical school.Secondary analysis of de-identified data from a retrospective national-cohort study was conducted for individuals who completed the 2001-2006 Association of American Medical Colleges (AAMC) Pre-Medical College Admission Test Questionnaire (PMQ) and the Medical College Admissions Test (MCAT). AAMC provided medical school application, acceptance, and matriculation data through 06/09/2013. Multivariable logistic regression models identified demographic, academic, and experiential variables independently associated with each outcome and differences between first-generation and continuing-generation students. Of 262,813 PMQ respondents, 211,216 (80.4%) MCAT examinees had complete data for analysis and 24.8% self-identified as first-generation college graduates. Of these, 142,847 (67.6%) applied to U.S. MD-degree-granting medical schools, of whom 86,486 (60.5%) were accepted, including 14,708 (17.0%) first-generation graduates; 84,844 (98.1%) acceptees matriculated. Adjusting for all variables, first-generation (vs. continuing-generation) college graduates were less likely to apply (odds ratio [aOR] 0.84; 95% confidence interval [CI], 0.82-0.86) and be accepted (aOR 0.86; 95% CI, 0.83-0.88) to medical school; accepted first-generation college graduates were as likely as their continuing-generation peers to matriculate. Students with (vs. without) paid work experience outside hospitals/labs/clinics were less likely to apply, be accepted, and matriculate into medical school. Increased efforts to mitigate structural socioeconomic vulnerabilities that may prevent first-generation college students from applying to medical school are needed. Expanded use of holistic review admissions practices may help decision makers value the strengths first-generation college graduates and other underrepresented applicants bring to medical educationand the physician workforce.

Academic redlining in medicine.

Despite concerted efforts over the past decade to increase diversity in U.S. medical schools, persistent applicant and enrollment gaps remain for students from underrepresented racial and economic backgrounds. To understand these gaps, we propose a new theory of 'academic redlining' as a widespread practice in medical schools that systematically excludes students from underrepresented backgrounds from entry into medicine through the nearly universal use of Medical College Admissions Test (MCAT) cutoff scores. In this paper, we provide evidence that academic redlining via the MCAT disenfranchises students from underrepresented backgrounds prior to and during the admissions process due to structural racism, and describe the three core mechanisms that cause medical schools to engage in academic redlining: (1) the pursuit of institutional prestige, (2) market competition and pressure, and (3) market bands. Given the persistent lack of diversity in medicine-which contributes to devastating health care disparities-as medical schools redouble their commitments to diversity, equity, and inclusion, structural alternatives within medical schools' admissions and education practices are offered to curtail the practice of academic redlining in medical school admissions and medicine.

Office of Student Affairs: Engagement and Leadership Opportunities for Medical Students, Residents, and Fellows.

Introduction: Exposing trainees to roles within medical school offices is an important, but often overlooked, component of academic medicine career development. This module described the roles and responsibilities of staff within the Office of Student Affairs (OSA) and opportunities for trainees to become engaged, lead, and develop student affairs-related competencies. Methods: The 90-minute workshop was presented at three regional conferences at US medical schools between September and December 2019. Participants were medical students, residents, and fellows from multiple institutions. The workshop consisted of a didactic portion describing OSA responsibilities and guiding principles, reflection exercises to gauge learners' engagement with the OSA, and case discussions on how trainees have led scholarly student affairs-related projects. Results: Among 28 participants, over 90%, agreed that each of the workshop objectives was met. Using the Wilcoxon signed-rank test, there was a statistically significant increase (p < .001) in participants' confidence to "list skills to be an effective advisor in the OSA," and, "Advocate for student issues through the OSA." Discussion: Trainees not only have the opportunity to access services through the OSA, but also serve and develop foundational competencies to eventually serve in an OSA leadership position. This workshop provided trainees early exposure to OSA administration to realize a career in academic medicine beyond the faculty role.

Enrollment Management in Undergraduate Medical School Admissions: A Complementary Framework to Holistic Review for Increasing Diversity in Medicine.

Medical schools implemented holistic review more than a decade ago, which led to more deliberate consideration and inclusion of applicants historically underrepresented in medicine. This article presents a theory of holistic enrollment management that unites holistic review with enrollment management principles. This theory contextualizes medical school admissions as a complex marketplace with multifaceted, competing forces. Applying an enrollment management framework of mission, market, means, and metrics can improve the capacity of a medical school to efficiently advance its mission over time. Medical schools employing a clear, compelling, and focused mission to direct all aspects of the medical education enterprise can more effectively attract applicants who are better prepared to enact that mission throughout their careers. Medical schools share a marketplace and collectively compete to identify, attract, admit, and matriculate the most mission-aligned student body within the pool of applicants they share. Institutions that deliberately mobilize resources within this dynamic marketplace will engage, admit, and matriculate the most suiting applicants and attract even more mission-aligned matriculants over time. Widespread adoption of this holistic framework of enrollment management may enhance the capacity of the medical education system to better capitalize on the existing diversity in the national pool of applicants, encourage more underrepresented applicants to apply in the future, admit and matriculate a more diverse national student body, and ultimately better prepare new physicians to meet the increasingly diverse health care needs of the nation.

Office of Admissions: Engagement and Leadership Opportunities for Trainees.

Introduction: Encouraging trainee engagement with the Office of Admissions can be an effective method of training for a future career in academic medicine and allow trainees to develop critical leadership skills. Methods: This workshop consisted of a short didactic presentation, a large-group activity, and case discussions in an effort to address four objectives describing the functions of the Office of Admissions, as well as identifying opportunities for involvement and leadership skills fostered through engaging in admissions activities. The module was administered to diverse students and residents at three regional conferences at US medical schools between September and December 2019. Pre- and postworkshop surveys were used to analyze the efficacy of the workshop. Results: More than 95% of the 70 learners agreed that all four objectives had been met. Additionally, trainees had a statistically significant increase (p < .001) in confidence in their ability to address new issues, such as Deferred Action for Childhood Arrivals or LGBT inclusion, through the admissions process and engage in discussion about admissions policies and practices. Discussion: This workshop was an effective tool for introducing trainees to leadership opportunities in academic medicine via involvement with the Office of Admissions. During the workshop, students expressed feedback about wanting more ways to become involved and more examples of student involvement. Attendees might also benefit from being encouraged to research the admissions processes and leadership structures at their respective institutions.

Helping Trainees Develop Scholarship in Academic Medicine From Community Service.

Introduction: Service in the community and academic medicine are often seen by trainees as unrelated. This may be one reason for the lack of faculty diversity and the declining interest in academic medicine among new trainees. Methods: We developed an educational workshop through the application of the Kern model to help medical students and residents understand the relationship between community service work and scholarship as it pertains to a career in academic medicine. Specifically, the workshop helped trainees (1) understand the terms service and scholarship, (2) understand the benefits of achieving community service scholarship, and (3) identify steps to achieve community service scholarship through mock cases and personal stories. Results: The workshop was implemented at five conferences with a total of 139 trainees. Results of a paired-samples t test of learners' responses pre- and postworkshop showed statistically significant growth in their confidence to publish service-related work, as well as more positive agreement with the notion that community service work aligns with an academic medicine career. Discussion: This effective module can help trainees understand how community service and academic medicine are aligned, and raise their confidence in building a foundation for an academic medicine career through conducting community service scholarship.

Considerations for Residency Programs Regarding Accepting Undocumented Students Who Are DACA Recipients.

The Deferred Action for Childhood Arrivals (DACA) initiative provides for the temporary deferral of enforcement of immigration laws for certain undocumented individuals brought to the United States before age 16. More than 50 medical schools now consider applicants who are DACA recipients, and medical school graduates with DACA are eligible to continue their training in graduate medical education. In this article, the authors summarize current policy and provide data on DACA recipients in medical school. They then review the implications for considering DACA recipients in graduate medical education, including employment guidelines, employer responsibilities, training at Veterans Affairs facilities, research funding, and professional licensure. They conclude by discussing the future of the DACA program and best practices for supporting students who are DACA recipients.First, there are no employment restrictions for DACA recipients with valid work authorization documents as long as their employers use Form I-9 Employment Eligibility Verification. Second, unlike H-1B or J-1 visa holders, DACA recipients do not generate additional immigration-related costs for their residency programs. Next, provisions in the Civil Rights Act prohibit employers from discriminating against applicants based on national origin or, in some cases, citizenship status. Furthermore, trainees with DACA are eligible to rotate through Veterans Affairs facilities. Finally, some states, like California and New York, have adopted policies and regulations allowing trainees with DACA who meet all professional requirements to receive a medical license. Given this state of affairs, DACA recipients should have equal standing to their peers when being evaluated for residency positions.