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.

Perspectives on National Institutes of Health Funding Requirements for Racial and Ethnic Diversity Among Medical Scientist Training Program Leadership.

Importance: Since 1964, the National Institutes of Health (NIH) has funded the Medical Scientist Training Program (MSTP) MD-PhD program at medical schools across the US to support training physician-scientists. Recent studies have suggested that MSTPs have consistently matriculated more students from racial and ethnic backgrounds historically underrepresented in science than MD-PhD programs without NIH funding; however, the underlying basis for the increased diversity seen in NIH-funded MSTPs is poorly understood. Objective: To investigate how administrators and faculty perceive the impact of MSTP status on MD-PhD program matriculant racial and ethnic diversity. Design, Setting, and Participants: This qualitative study used a positive deviance approach to identify 9 high-performing and 3 low-performing MSTPs based on the percentage of students underrepresented in science who matriculated into the program between 2014 and 2018. This study, a subanalysis of a larger study to understand recruitment of students underrepresented in science at MSTPs, focused on in-depth qualitative interviews, conducted from October 26, 2020, to August 31, 2022, of 69 members of MSTP leadership, including program directors, associate and assistant program directors, and program administrators. Main Outcomes and Measures: The association of NIH funding with institutional priorities, programs, and practices related to MD-PhD program matriculant racial and ethnic diversity. Results: The study included 69 participants (mean [SD] age, 53 [10] years; 38 women [55%]; 13 African American or Black participants [19%], 6 Asian participants [9%], 12 Hispanic participants [17%], and 36 non-Hispanic White participants [52%]). A total of 51 participants (74%) were in administrative roles, and 18 (26%) were faculty involved in recruitment. Five themes emerged from the data: (1) by tying MSTP funding to diversity efforts, the NIH created a sense of urgency among MSTP leadership to bolster matriculant diversity; (2) MD-PhD program leadership leveraged the changes to MSTP grant review to secure new institutional investments to promote recruitment of students underrepresented in science; (3) MSTPs increasingly adopted holistic review to evaluate applicants to meet NIH funding requirements; (4) MSTP leadership began to systematically assess the effectiveness of their diversity initiatives and proactively identify opportunities to enhance matriculant diversity; and (5) although all MSTPs were required to respond to NIH criteria, changes made by low-performing programs generally lacked the robustness demonstrated by high-performing programs. Conclusions and Relevance: This study suggests that NIH funding requirements may be a powerful incentive to promote diversity and positively affect representation of students underrepresented in science in the biomedical scientific workforce.

Achieving Gender Equity Is Our Responsibility: Leadership Matters.

Across academic medicine, and particularly among faculty and medical school leadership, the status quo is unacceptable when it comes to gender diversity, equity, and inclusion. The Association of American Medical Colleges has launched a bold gender equity initiative, endorsed by its Board of Directors, to implore academic medical institutions to take meaningful and effective actions.Defining what progress should look like to guide these actions is worth deeper exploration. It is not enough to measure the representation of different genders at various levels of leadership within our institutions. Research and experience we share suggests more must be done, especially for women of diverse racial and ethnic backgrounds. What is needed is a fundamental conversation about privilege, intersectionality across different backgrounds, and progress.Institutional leaders have a choice to make. Will we make gender equity a top priority system-wide because we recognize that doing so leads to organizational excellence? Do we understand that establishing a robust, comprehensive definition of gender equity and how it is practiced will result in better outcomes for all? And are we ready and able to prioritize and be accountable for efforts that are measurable, with clear definitions of progress; driven and reinforced by leadership directives; inclusive of all, including men as well as women of diverse backgrounds and orientations; and systemic rather than ad-hoc? Implementing such actions requires initiating difficult conversations, making conscious choices, and modeling best practices from leaders who have successfully made gender equity a priority.

A Stochastic Model of Consensus Reaching in Committee Decisions for Faculty Advancement, Promotion and Tenure: Does Diversity Matter?

PURPOSE: There are considerable gender and racial disparities in academic promotions regardless of academic qualifications, suggesting bias. The investigators studied the academic promotions process by simulating the work of Advancement, Promotion and Tenure (APT) committees and applying a mathematical model to assess the impact of diversity on consensus reaching. METHOD: The study targeted academic faculty during an annual Association of American Medical Colleges (AAMC) meeting. Participants evaluated the academic dossier of a male Assistant Professor with a focus on community engagement during four simulations. All dossiers were identical, with the singular exception of the candidate's race (white vs. black). Committee composition varied with respect to racial diversity. Participants scored the candidate before and after the deliberations. The DeGroot Model was used to compare individual scoring to group convergence. RESULTS: While there was no statistically significant difference in the candidate's overall scores between the groups, the least diverse groups rated the candidate the lowest (p = 0.0595). Participants ranked activities related to diversity and equity as the least important. Moreover, criteria deliberated more heavily showed significant score changes after deliberation. Lastly, ambiguity about the review process at various institutions was reported by project participants, increasing the opportunity for bias in real world situations. CONCLUSIONS: While there was not enough statistical power to measure intragroup differences, the model shows promise in illuminating how individual perceptions, committee composition and group dynamics sway consensus reaching. The model also suggests that social research, community engagement and diversity work do not carry the same weight as traditional scholarship, impacting the career trajectory of minority scholars. The model can be used to evaluate bias not only in academic promotions but also in admissions, hiring and grant review. This will allow improved methods and processes for equitable academic performance reviews, enhancing the career trajectory and retention of minority scholars.

Racial and Ethnic Differences Between Obstetrician-Gynecologists and Other Adult Medical Specialists.

OBJECTIVE: To compare racial and ethnic differences between obstetrician-gynecologists (ob-gyns) and other large groups of adult medical specialists who provide the predominant care of women. Whether physician diversity influences their practice locations in underserved areas was also sought. METHODS: This cross-sectional study reports an analysis of U.S. national data about racial and ethnic characteristics, gender, and specialty (obstetrics and gynecology, general internal medicine, family medicine, emergency medicine) of 190,379 physicians who came from three resources (Association of American Medical Colleges Student Records System, Association of American Medical Colleges Minority Physicians Database, American Medical Association Physician Masterfile). Underserved locations were identified as being rural, having 20% or more of the population living in poverty or being federally designated as areas of professional shortages or underserved populations. Bivariate measures of associations were performed to study the association between physician race and ethnicity and their practice location. RESULTS: Female physicians in all specialties were more likely than males to be nonwhite, and ob-gyns were most likely to be female (61.9%). Compared with other studied specialists, ob-gyns had the highest proportion of underrepresented minorities (combined, 18.4%), especially black (11.1%) and Hispanic (6.7%) physicians. Underrepresented minority ob-gyns were more likely than white or Asians to practice in federally funded underserved areas or where poverty levels were high. Native Americans, Alaska Natives, and Pacific Islanders were the ob-gyn group with the highest proportion practicing in rural areas. CONCLUSION: Compared with other adult medical specialists, ob-gyns have a relatively high proportion of black and Hispanic physicians. A higher proportion of underrepresented minority ob-gyns practiced at medically underserved areas.

Measuring Diversity and Inclusion in Academic Medicine: The Diversity Engagement Survey.

PURPOSE: To produce a physician and scientific workforce that advances high-quality research and culturally competent care, academic medical centers (AMCs) must assess their capacity for diversity and inclusion and leverage opportunities for improvement. The Diversity Engagement Survey (DES) is presented as a diagnostic and benchmarking tool. METHOD: The 22-item DES consists of eight factors that connect engagement theory to inclusion and diversity constructs. It was piloted at 1 AMC and then administered at 13 additional U.S. AMCs in 2011-2012. Face and content validity were assessed through a review panel. Cronbach alpha was used to assess internal consistency. Confirmatory factor analysis (CFA) was used to establish construct validity. Cluster analysis was conducted to establish ability of the DES to distinguish between institutions' degrees of engagement and inclusion. Criterion validity was established using observed differences in scores for demographic groups as suggested by the literature. RESULTS: The sample included 13,694 respondents across 14 AMCs. Cronbach alphas for the engagement and inclusion factors (range: 0.68-0.85), CFA fit indices, and item correlations with latent constructs indicated an acceptable model fit and that items measured the intended concepts. Cluster analysis of DES scores distinguished institutions with higher, middle, and lower degrees of engagement and inclusion by their respondents. Consistent with the literature, black, Hispanic/Latino, female, and LGBTQ (lesbian, gay, bisexual, transgender, queer) respondents reported lower degrees of engagement than their counterparts. CONCLUSIONS: The DES is a reliable and valid instrument for assessment, evaluation, and external benchmarking of institutional engagement and inclusion.

Racial and ethnic minority medical students' perceptions of and interest in careers in academic medicine.

PURPOSE: To describe diverse medical students' perceptions of and interest in careers in academic medicine. METHOD: In 2010, the authors invited students attending three national medical student conferences to respond to a survey and participate in six focus groups. The authors identified trends in data through bivariate analyses of the quantitative dataset and using a grounded theory approach in their analysis of focus group transcripts. RESULTS: The 601 survey respondents represented 103 U.S. medical schools. The majority (72%) were in their first or second year; 34% were black and 17% were Hispanic. Many respondents (64%) expressed interest in careers in academic medicine; teaching and research were viewed as positive influences on that interest. However, black and Hispanic respondents felt they would have a harder time succeeding in academia. The 73 focus group participants (25% black, 29% Hispanic) described individual- and institutional-level challenges to academic medicine careers and offered recommendations. They desired deliberate and coordinated exposure to academic career paths, research training, clarification of the promotion process, mentorship, protected time for faculty to provide teaching and research training, and an enhanced infrastructure to support diversity and inclusion. CONCLUSIONS: Medical students expressed an early interest in academic medicine but lacked clarity about the career path. Black and Hispanic students' perceptions of having greater difficulty succeeding in academia may be an obstacle to engaging them in the prospective pool of academicians. Strategic and dedicated institutional resources are needed to encourage racial and ethnic minority medical students to explore careers in academic medicine.

Assessing the evolving definition of underrepresented minority and its application in academic medicine.

PURPOSE: To assess how U.S. academic health centers (AHCs) define the term underrepresented minority (URM) and apply it to their diversity programs, following the 2003 revision of the Association of American Medical Colleges' (AAMC's) definition of URM. METHOD: In 2010, the authors developed and deployed a cross-sectional survey of diversity leaders at 106 AHCs. The survey included questions about the diversity leader and institution's diversity program; institution's URM definition; application of that definition; and the diversity leader's perceptions of the representation and institutional contribution of various ethnic/racial groups. The authors used descriptive statistics to analyze the results. RESULTS: Of the 106 diversity leaders invited, 89 (84.0%) responded and 78 (73.6%) provided a working definition of URM. Most programs (40/78; 51%) used the 2003 AAMC definition of URM, which includes racial/ethnic groups that are underrepresented in medicine relative to local and national demographics. Only 14.1% (11/78) used the pre-2003 AAMC definition, which included only African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. Approximately one-third (23/78; 29.5%) also considered other diversity factors, such as socioeconomic status, sexual orientation, and disability, in defining URM. Fifty-eight respondents (74.4%) confirmed that their diversity programs targeted specific groups. CONCLUSIONS: The definition of URM used by diversity programs at U.S. AHCs varied widely. Although some classified URMs by racial/ethnic categories, the majority defined URM more broadly to encompass other demographic and personal characteristics. This shift should prepare academic medicine to eliminate health disparities and meet the health needs of an increasingly diverse population.

Institutional variation in the promotion of racial/ethnic minority faculty at US medical schools.

OBJECTIVES: We compared faculty promotion rates by race/ethnicity across US academic medical centers. METHODS: We used the Association of American Medical College's 1983 through 2000 faculty roster data to estimate median institution-specific promotion rates for assistant professor to associate professor and for associate professor to full professor. In unadjusted analyses, we compared medians for Hispanic and Black with White faculty using the Wilcoxon rank sum test. We compared institution-specific promotion rates between racial/ethnic groups with data stratified by institutional characteristic (institution size, proportion racial/ethnic minority faculty, and proportion women faculty) using the χ(2) test. Our sample included 128 academic medical centers and 88, 432 unique faculty. RESULTS: The median institution-specific promotion rates for White, Hispanic, and Black faculty, respectively, were 30.2%, 23.5%, and 18.8% (P < .01) from assistant to associate professor and 31.5%, 25.0%, and 16.7% (P < .01) from associate to full professor. CONCLUSIONS: At most academic medical centers, promotion rates for Hispanic and Black were lower than those for White faculty. Equitable faculty promotion rates may reflect institutional climates that support the successful development of racial/ethnic minority trainees, ultimately improving healthcare access and quality for all patients.

Faculty diversity programs in U.S. medical schools and characteristics associated with higher faculty diversity.

PURPOSE: To describe diversity programs for racial and ethnic minority faculty in U.S. medical schools and identify characteristics associated with higher faculty diversity. METHOD: The authors conducted a cross-sectional survey study of leaders of diversity programs at 106 U.S. MD-granting medical schools in 2010. Main outcome measures included African American and Latino faculty representation, with correlations to diversity program characteristics, minority medical student representation, and state demographics. RESULTS: Responses were obtained from 82 of the 106 institutions (77.4%). The majority of the respondents were deans, associate and assistant deans (68.3%), members of minority ethnic/racial background (65.9% African American, 14.7% Latino), and women (63.4%). The average time in the current position was 6.7 years, with approximately 50% effort devoted to the diversity program. Most programs targeted medical trainees and faculty (63.4%). A majority of programs received monetary support from their institutions (82.9%). In bivariate analysis, none of the program characteristics measured were associated with higher than the mean minority faculty representation in 2008 (3% African American and 4.2% Latino faculty). However, minority state demographics in 2008, and proportion of minority medical students a decade earlier, were significantly associated with minority faculty representation. CONCLUSIONS: Medical student diversity 10 years earlier was the strongest modifiable factor associated with faculty diversity. Our results support intervening early to strengthen the minority medical student pipeline to improve faculty diversity. Schools located in states with low minority representation may need to commit additional effort to realize institutional diversity.

Commentary: the building the next generation of academic physicians initiative: engaging medical students and residents.

Data from the 2010 U.S. Census are a reminder of the diverse patient population in the United States and the growing health care needs of Americans. Academic health centers are tasked with reforming the system to expand its capacity for care and with cultivating innovation to generate the teaching, training, and research prowess needed to eliminate health disparities. At the center of this reform is enhancing the system that produces the human capital, including the physicians who care for the patients and the educators who train those physicians. Institutions and foundations have committed to the development of pipeline programs, from kindergarten through college, to create a diverse clinical workforce, but they have limited their direct promotion of diversity in the academic medicine workforce to faculty development programs. Despite faculty efforts, shortcomings in diversity persist, including a paucity of female full professors and deans, an insignificant increase in the proportion of underrepresented racial and ethnic minority faculty, and a lack of knowledge on the cultivation of the lesbian and gay faculty perspective. Furthermore, underrepresented racial and ethnic minority students in particular lose interest in academic medicine careers during medical school, and overall students lose interest in academic medicine careers during residency. The Building the Next Generation of Academic Physicians Initiative is designed to develop interest and promote achievement in pursuing academic medicine careers. This initiative is needed to increase the pool of diverse faculty down the road and elicit their perspectives to more effectively address health care disparities.

Minority faculty members' resilience and academic productivity: are they related?

PURPOSE: To explore whether there is a relationship between resilience and academic productivity of minority faculty members in U.S. academic health centers. For the purposes of the study, the authors defined academic productivity as peer-reviewed and non-peer-reviewed publications, grants, and academic promotion. METHOD: In 2007, the authors simultaneously collected quantitative and qualitative data by using a triangulation (mixed-method) design. Past participants in the Association of American Medical Colleges' Minority Faculty Career Development Seminar completed the Web-based 70-item Personal Resilience Questionnaire (PRQ). In addition, two focus groups were conducted with past seminar participants. RESULTS: Seventy-four minority faculty members completed the PRQ, and 15 participated in the two focus groups. The quantitative data showed a positive correlation between demographic, educational, and academic productivity variables and certain resilience subscale scores. Common themes that emerged from the qualitative data were categorized under four major domains: existing barriers to academic advancement, internal protective factors or cultural buffers, external institutional or environmental facilitators, and necessary attributes for ensuring academic productivity and advancement. CONCLUSIONS: Certain resilience subscales showed correlation with academic productivity of minority faculty members, and specific personal and/or cultural characteristics were identified as enablers. Minority faculty members may benefit from skill development and coaching that extends beyond the traditional scope of faculty development programs and that specifically targets modifiable resilience characteristics. Additional research is needed, but such nontraditional, resilience-centered intervention strategies may positively affect the advancement of minority faculty in academic medicine.