Underrepresented in medicine (URiM) residents: A scoping review on prevalence trends & improving recruitment.

BACKGROUND: Disparities exist in underrepresented in medicine (URiM) resident representation. This review examines recent trends in resident diversity, URiM recruitment strategies, and identifies research gaps in equity, diversity, and inclusion (EDI) for URiM residents. METHODS: MEDLINE, EMBASE, Web of Science, and ERIC databases were searched for studies published from 2017 to 2022 on URiM resident prevalence and recruitment initiatives. RESULTS: 3634 abstracts were reviewed, and 52 articles were included. 35 (67 â€‹%) studies reported on prevalence of URiM residents, demonstrating URiM resident composition is lower than residency applicant demographics, particularly in surgery. Seventeen (33 â€‹%) studies reported on URiM recruitment interventions, such as visiting clerkship programs, holistic review, and targeted outreach, and demonstrated success in increasing recruitment of URiM candidates to programs. CONCLUSIONS: URiM residents remain disproportionately underrepresented, and markedly so among surgical residency programs. Further research should focus on implementing EDI interventions in surgery and assess URiM resident attrition post-matriculation.

Geographic and demographic trends with the initiation of virtual interviews in general surgery: A 7-program evaluation.

BACKGROUND: Although most general surgery residency interviews remain virtual, the effect of this format remains understudied. Single-institution data have shown an increase in the number of applications received and interviews conducted with virtual interviewing but no change in the geographic backgrounds of interviewed or matched applicants. This study sought to compare national trends in geographic characteristics of general surgery applicants, interviewed applicants, and matched applicants between in-person and virtual application cycles. STUDY DESIGN: A retrospective review of 7 general surgery residency programs from application years 2016-2019 (in-person) and 2020-2021 (virtual) was conducted. Data collected included birth year, sex, race, medical school state, and contact location at the time of application. Data were analyzed using generalized mixed effects linear models. RESULTS: A total of 52,742 applicants, 4,550 interviewed applicants, and 329 matched applicants were included. During virtual application cycles, there were no increases in the average number of applicants (P = .25), interviewed applicants (P = .36), or matched (P = .84) applicants per year. Virtual cycles were associated with a larger proportion of interviews conducted with applicants from out-of-state medical schools (P < .01) and listing out-of-state contact locations (P < .01) compared with in-person application cycles. There were no significant geographic differences in matched applicants between virtual and in-person application cycles. CONCLUSION: Virtual application cycles had greater geographic diversity among interviewed applicants. However, similar differences were not seen in the geographic diversity of matched applicants. Additional efforts should focus on why no changes in the geographic diversity of matched applicants were identified.

How Did Black and Hispanic Orthopaedic Applicants and Residents Compare to General Surgery Between 2015 and 2022?

BACKGROUND: Despite the heavy demand for and knowledge of the benefits of diversity, there is a persistent lack of racial, ethnic, and gender diversity in orthopaedic surgery. Since the implementation of diversity initiatives, data have shown that general surgery has been one of the top competitive surgical fields and has demonstrated growth in racial, ethnic, and gender diversity, making general surgery a good point of reference and comparison when analyzing racial and ethnic growth in orthopaedic surgery. QUESTIONS/PURPOSES: (1) What were the growth rates for Black and Hispanic orthopaedic residency applicants and residents between 2015 and 2022? (2) How did the growth rates of Black and Hispanic individuals in orthopaedic surgery compare with those of general surgery? (3) How did applicant recruitment and resident acceptance differ between Black and Hispanic people in orthopaedic surgery? METHODS: Applicant data were obtained from historical specialty-specific data from the Association of American Medical Colleges Electronic Residency Application Service Statistics database between 2018 and 2022, and resident data were obtained from the Accreditation Council of Graduate Medical Education Data Resource Book between 2015 and 2021. Between 2018 and 2022, the number of residency applicants totaled 216,677, with 17,912 Black residency applicants and 20,413 Hispanic residency applicants. Between 2015 and 2021, the number of active residents totaled 977,877, with 48,600 Black residents and 62,605 Hispanic residents. Because the applicant and resident data do not overlap throughout all years of observation, a sensitivity analysis of overlapping years (between 2018 and 2021) was conducted to ensure observed trends were consistent and valid throughout the study. All datasets obtained were used to establish the different racial and ethnic proportions of Black and Hispanic residency applicants and residents in four nonsurgical primary care specialties and four surgical subspecialties. A reference slope was created using data from the Association of American Medical Colleges and Accreditation Council of Graduate Medical Education to represent the growth rate for total residency applicants and residents, independently, across all residency specialties reported in each database. This slope was used for comparison among the resident and applicant growth rates for all eight selected specialties. Datapoints were placed into a scatterplot with regression lines, using slope equations to depict rate of growth and R 2 values to depict linear fit. Applicant growth corresponded to applicant recruitment and resident growth corresponded to resident acceptance. Chi-square tests were used to compare residents and residency applicants for the Black and Hispanic populations, separately. Two-way analysis of variance with a time-by-specialty interaction term (F-test) was conducted to determine differences between growth slopes. RESULTS: There was no difference in the growth rate of Black orthopaedic surgery applicants between 2018 and 2022, and there was no difference in the growth rate of Hispanic orthopaedic surgery applicants (R 2 = 0.43; p = 0.23 and R 2 = 0.63; p = 0.11, respectively). However, there was a very slight increase in the growth rate of Black orthopaedic surgery residents between 2015 and 2021, and a very slight increase in the growth rate of Hispanic orthopaedic surgery residents (R 2 = 0.73; p = 0.02 and R 2 = 0.79; p = 0.01, respectively). There were no differences in orthopaedic and general surgery rates of growth for Black applicants between 2018 and 2022 (0.004 applicants/year versus -0.001 applicants/year; p = 0.22), and no differences were found in orthopaedic and general surgery rates of growth for Black residents between 2015 and 2021 (0.003 residents/year versus 0.002 residents/year; p = 0.59). Likewise, Hispanic orthopaedic applicant growth rates did not differ between 2018 and 2022 from the rates of general surgery (0.004 applicants/year versus 0.005 applicants/year; p = 0.68), and there were no differences in orthopaedic and general surgery rates of growth for Hispanic residents (0.007 residents/year versus 0.01 residents/year; p = 0.35). Furthermore, growth rate comparisons between Black orthopaedic applicants and residents between 2018 and 2021 showed applicant growth was larger than resident growth, illustrating that the recruitment of Black applicants increased slightly more rapidly than resident acceptance. Growth rate comparisons between Hispanic applicants and residents showed a larger rate of resident growth, illustrating Hispanic resident acceptance increased slightly faster than applicant recruitment during that time. CONCLUSION: We found low acceptance of Black residents compared with the higher recruitment of Black applicants, as well as overall low proportions of Black and Hispanic applicants and residents. Future studies might explore the factors contributing to the higher acceptances of Hispanic orthopaedic residents than Black orthopaedic residents. CLINICAL RELEVANCE: We recommend that more emphasis should be placed on increasing Black and Hispanic representation at the department level to ensure cultural considerations remain at the forefront of applicant recruitment. Internal or external reviews of residency selection processes should be considered, and more immersive, longitudinal orthopaedic surgery clerkships and research mentorship experiences should be targeted toward Black and Hispanic students. Holistic reviews of applications and selection processes should be implemented to produce an increased racially and ethnically diverse applicant pool and a diverse residency work force, and implicit bias training should be implemented to address potential biases and diversity barriers that are present in residency programs and leadership.

How real is a virtual interview? Perspectives of orthopaedic surgery residency directors.

OBJECTIVE: As a result of COVID-19 pandemic, the 2021 US residency MATCH was devoid of the traditional in-person interviews. Herein, we assess the impact of Virtual Interviews (VIs) on resident selection, from the perspectives of Orthopedic Surgery (OS) Program Directors (PDs). MATERIALS AND METHODS: A 14-item survey was sent to PDs of ACGME-accredited OS residencies. Questions were designed to assess the pros, cons, and robustness of VIs compared to their antecedent in-person format. RESULTS: Forty-seven PDs responded to our survey. VIs antagonized PDs' ability to assess applicants' fit to program (76.6%), commitment to specialty (64%), and interpersonal skills (68.1%). This led to heavier dependence upon applicants' portfolios (64%). Almost all respondents (97.9%) found VIs to be more cost-efficient, saving a median of $3000 in interview-related expenses. Overall, only 8.5% of PDs were willing to conduct exclusive VIs in future cycles, compared to the majority in favor of dual formats (51.5%) or exclusive in-person interviews (40.4%). CONCLUSIONS: VIs have been an overall success, making most PDs opt for dual interview formats in future cycles. How this technology is further implemented in the future remains to be seen.

Pass/Fail Scoring of USMLE Step 1 and the Need for Residency Selection Reform.

The Federation of State Medical Boards and the National Board of Medical Examiners recently announced a change in the United States Medical Licensing Examination Step 1 scoring convention to take effect, at the earliest, on January 1, 2022. There are many reasons for this change, including decreasing medical student stress and incentivizing students to learn freely without solely focusing on Step 1 performance. The question remains how this will affect the future of the otolaryngology-head and neck surgery match. By eradicating Step 1 grades, other factors, such as research, may garner increased importance in the application process. Such a shift may discriminate against students from less well-known medical schools, international medical graduates, and students from low socioeconomic backgrounds, who have fewer academic resources and access to research. Residency programs should try to anticipate such unintended consequences of the change and work on solutions heading into 2022.

Virtual Interviews for the Independent Plastic Surgery Match: A Modern Convenience or a Modern Misrepresentation?

OBJECTIVE: The virtual interview for residency and fellowship applicants has previously been utilized preliminarily in their respective processes. The COVID-19 pandemic forced many programs to switch to a virtual interview process on short notice. In the independent plastic surgery process, which was underway when the pandemic started, applicants had a heterogeneous experience of in-person and virtual interviews. The purpose of this study was to assess if applicants prefer a virtual interview experience to an in-person interview as well as determine if virtual interview applicants had a different opinion of a program compared to the in-person interview applicants. DESIGN/SETTING/PARTICIPANTS: The 2019 to 2020 applicants who interviewed at the Indiana University Independent Plastic Surgery program were administered an anonymous online survey about their interview experience at our program. RESULTS: Our survey response was 60% (18/30). The in-person interview group (n = 10) rated their overall interview experience higher than the virtual interview group (n = 8) 8.8 vs 7.5 (p = 0.0314). The in-person interview group felt they became more acquainted with the program, the faculty, and the residents more than the virtual group (4.7 vs 3.25, p < 0.0001) (4.3 vs 3.25, p = 0.0194) (4.3 vs 2.75, p < 0.0001). The majority of applicants favored in-person interviews (16/18, 88.9%). The in-person interview group spent significantly more money on their interview at our program compared to the virtual interview group ($587 vs $0, p < 0.0001). CONCLUSION: Our study demonstrated that the virtual interview process was an efficient process for applicants from both a financial and time perspective. However, the virtual interview process left applicants less satisfied with their interview experience. The applicants felt they did not become as acquainted with the program as their in-person counterparts. The virtual interview process may play a large role in residency and fellowship applications in the future, and programs should spend time on how to improve the process.

Update on workforce diversity in vascular surgery.

OBJECTIVE: Creating a diverse workforce is paramount to the success of the surgical field. A diverse workforce allows us to meet the health needs of an increasingly diverse population and to bring new ideas to spur technical innovation. The purpose of this study was to assess trends in workforce diversity within vascular surgery (VS) and general surgery (GS) as compared with orthopedic surgery (OS)-a specialty that instituted a formal diversity initiative over a decade ago. METHODS: Data on the trainee pool for VS (fellowships and integrated residencies), GS, and OS were obtained from the U.S. Graduate Medical Education reports for 1999 through 2017. Medical student demographic data were obtained from the Association of American Medical Colleges U.S. medical school enrollment reports. The representation of surgical trainee populations (female, Hispanic, and black) was normalized by their representation in medical school. We also performed the χ2 test to compare proportions of residents over dichotomized time periods (1999-2005 and 2013-2017) as well as a more sensitive trend of proportions test. RESULTS: The proportion of female trainees increased significantly between the time periods for the three surgical disciplines examined (P < .001). Hispanic trainees also represented an increasing proportion of all three disciplines (P ≤ .001). The proportion of black trainees did not significantly change in any discipline between the two periods. Relative to their proportion in medical school, Hispanic trainees were well represented in all surgical specialties studied (normalized ratio [NR], 0.95-1.52: 0.95 OS, 1.00 GS, 1.53 VS fellowship, and 1.23 VS residency). Compared with their representation in medical school, women were under-represented as surgical trainees (NR: 0.32 OS, 0.82 GS, 0.56 VS fellowship, and 0.78 VS residency) as were black trainees (NR: 0.63 OS, 0.90 GS, 0.99 VS fellowship, and 0.81 VS residency). CONCLUSIONS: Although there were significant increases in the number of women and Hispanic trainees in these three surgical disciplines, only Hispanic trainees enter the surgical field at a rate higher than their proportion in medical school. The lack of an increase in black trainees across all specialties was particularly discouraging. Women and black trainees were under-represented in all specialties as compared with their representation in medical school. The data presented suggest potential problems with recruitment at multiple levels of the pipeline. Particular attention should be paid to increasing the pool of minority medical school graduates who are both interested in and competitive for surgical specialties.

Direct Comparison of In-Person Versus Virtual Interviews for Complex General Surgical Oncology Fellowship in the COVID-19 Era.

BACKGROUND: In the era of coronavirus disease 2019 (COVID-19), many Complex General Surgical Oncology (CGSO) fellowship programs implemented virtual interviews (VI) during the 2020 interview season. At our institution, we had the unique opportunity to conduct an in-person interview (IPI) prior to the pandemic-related travel restrictions, and a VI after the restrictions were in place. OBJECTIVE: The goal of this study was to understand how the VI model compares with the traditional IPI approach. METHODS: Online surveys were distributed to both groups, collecting feedback on their interview experience. Responses were evaluated using a two-sample t test assuming equal variances. RESULTS: Twenty-three of 26 (88%) applicants completed the survey. Most applicants reported that the interview gave them a satisfactory understanding of the CGSO fellowship (100% IPI, 92% VI) and the majority in both groups felt that the interview experience allowed them to accurately represent themselves (92% and 82%, respectively). All participants in the IPI group felt they were able to get an adequate understanding of the culture of the program, while only 64% in the VI group agreed with that statement (p = 0.02). IPI applicants were more likely to agree that the interview experience was sufficient to allow them to make a ranking decision (92% vs. 54%; p = 0.04). CONCLUSIONS: While the VI modality offers several advantages over the IPI, it still falls short in conveying some of the more subjective aspects of the programs, including program culture. Strategies to provide applicants with better insight into these areas during the VI will be important moving forward.

Otolaryngology Match Trends: Considerations for Proper Data Interpretation.

There is an extensive amount of data available from the leading organizations involved in the residency selection process. Tracking trends in otolaryngology residency applications and match outcomes is vital to understand the pipeline of individuals joining our profession. As we make changes to the application or match process, proper interpretation of available data is vital to prevent erroneous analyses and inappropriate conclusions. In the commentary, we explore the nuances of data from the Electronic Residency Application Service and National Residency Matching Program to help our specialty direct research endeavors and policy changes that will ultimately affect the makeup of our future workforce.

Virtual Surgical Fellowship Recruitment During COVID-19 and Its Implications for Resident/Fellow Recruitment in the Future.

BACKGROUND: The COVID-19 pandemic has overlapped with the scheduled interview periods of over 20 surgical subspecialty fellowships, including the Complex General Surgical Oncology (CGSO) fellowships in the National Resident Matching Program and the Society of Surgical Oncology's Breast Surgical Oncology fellowships. We outline the successful implementation of and processes behind a virtual interview day for CGSO fellowship recruitment after the start of the pandemic. METHODS: The virtual CGSO fellowship interview process at the University of Chicago Medicine and NorthShore University Health System was outlined and implemented. Separate voluntary, anonymous online secure feedback surveys were email distributed to interview applicants and faculty interviewers after the interview day concluded. RESULTS: Sixteen of 20 interview applicants (80.0%) and 12 of 13 faculty interviewers (92.3%) completed their respective feedback surveys. Seventy-five percent (12/16) of applicants and all faculty respondents (12/12) stated the interview process was 'very seamless' or 'seamless'. Applicants and faculty highlighted decreased cost, time savings, and increased efficiency as some of the benefits to virtual interviewing. CONCLUSIONS: Current circumstances related to the COVID-19 pandemic require fellowship programs to adapt and conduct virtual interviews. Our report describes the successful implementation of a virtual interview process. This report describes the technical steps and pitfalls of organizing such an interview and provides insights into the experience of the interviewer and interviewee.

Trends in the 10-year history of the vascular integrated residency match: More work, higher cost, same result.

OBJECTIVE: The purpose of this study was to examine trends in application submission, rank lists, and applicant quality for vascular surgery integrated residency. METHODS: The National Resident Matching Program Results and Data reports and the Electronic Residency Application Service Statistics from 2007 to 2017 were compiled and mined for trends in terms of application submission and the number of applicants a program needed to rank to fill all residency positions. Applicant pool depth and percentage of programs applied to were calculated. Outcome data from the National Resident Matching Program were reviewed for 2014 and 2016 for United States Medical Licensing Examination Step scores and experiences. RESULTS: During the last 10 years, the number of vascular surgery integrated residency spots rose from 9 to 60 per year. Most programs offer one spot per year; none offer more than two. The average number of applications received by programs rose from 17 applications in 2008 to 63.8 in 2017. The average rank list depth needed by programs to fill the spots has not increased (range, 2.5-5.1; standard deviation, 0.73). The proportional depth of the applicant pool decreased from 4.6 U.S. and Canadian applicants for every one residency spot in 2008 to 1.7 applicants for every one residency spot in 2017. Applicant quality metrics were available for 2 years (2014 and 2016). Step 1 scores (237/239), Step 2 scores (250/250), research experiences (3.7/4.2), and volunteer experiences (5.9/5.5) remained nearly unchanged. The number of contiguous ranks for matched applicants remained stable (12.3/12.8). CONCLUSIONS: The current system promotes multiple inefficiencies, resulting in application glut. Fewer applicants are flooding programs with an increasing number of applications. More money is being spent on Electronic Residency Application Service applications without changes in the number needed to rank by applicants or programs to achieve a match. There is no improvement in the quality of the applicant. Should these trends continue, they represent an unsustainable model for resident selection.

Gender Differences in Pediatric Orthopaedics: What Are the Implications for the Future Workforce?

BACKGROUND: Although the number of women in surgical specialties has increased dramatically over the past two decades, little research exists regarding how a surgeon's gender impacts job selection and practice models. Because the number of women specializing in pediatric orthopaedics continues to increase, it is important to understand how one's gender affects practice choices and how this may affect the future workforce. QUESTIONS/PURPOSES: (1) Among pediatric orthopaedic surgeons, is gender associated with choice of practice type (academic, private practice, hospital-based, solo)? (2) For men and women, what are the most common reasons for choosing a job? (3) For new graduates, do men and women have equal starting salaries? (4) Do men have a higher chance of getting job offers? (5) Is there a difference in workload (call frequency and surgical case volume) for men and women? (6) Finally, is there a difference in imminent retirement plans for men and women? METHODS: The 2015 Pediatric Orthopaedic Society of North American (POSNA) Needs Assessment Survey was sent to POSNA members and a special 36-question survey was sent to recent pediatric orthopaedic fellowship graduates. Both surveys included questions about self-reported gender, practice type, reasons for job selection, and call frequency. In addition, the new graduates' survey also included questions about starting salary, job offers, and number of additional fellowships completed. Responses were analyzed by gender. Chi-square and Fisher's exact tests assessed for statistical significance. RESULTS: Among the new graduates, women are more likely to choose academic practice (women: 13 of 18 [72%], men: 21 of 44 [48%], odds ratio [OR], 3.10 [confidence interval {CI}, 0.86-11.10], p < 0.001), whereas men are more likely to choose private practice (men: 14 of 44 [32‰], women: one of 18 [6%], OR, 0.12 [CI, 0.015-1.001], p < 0.001). The primary reasons for choosing a job were not different between men and women. Among the new graduates, geography/family considerations were reported as being highly important when selecting a job (men: 33 of 44 [75%], women: 16 of 18 [89%]) followed by academic opportunities (men: 24 of 44 [55%], women: 14 of 18 [78%]). Interestingly, a higher percentage of males reported finances as being important when selecting a job (men: 23 of 44 [52%], women: five of 18 [28%]). For the current POSNA members, the most important reasons when choosing a job for both men and women were quality of partners (men: 168 of 408 [41%], women: 66 of 122 [54%]) and an interesting practice (men: 155 of 408 [38%], women 54 of 122 [44%]. As a result of our small sample size, there was no difference in starting salaries between men and women (< USD 350,000: men 22 of 44 [50%], women 12 of 18 [67%]; USD 350,000-450,000: men 11 of 44 [25%], women six of 18 [33%]; > USD 450,000: men eight of 44 [18%], women zero of 18 [0%], p = 0.131). When stratified by practice type, for private practice starting salaries, over half of men (seven of 13 [54%]) placed in the highest category of > USD 400,000, whereas the single woman respondent placed in the lowest category of < USD 300,000. Men were more likely to report having job offers before starting their fellowship (men: 24 of 44 [54%], women: eight of 18 [44%], OR, 0.67 [CI, 0.22-2.0], p = 0.042). Finally, among POSNA members, women reported a lower weekly surgical case volume compared with men. Of the men, 108 of 408 (26%) reported performing more than seven surgeries per week compared with 12 of 122 women (10%; OR, 3.4 [CI, 1.8-6.44], p < 0.001). CONCLUSIONS: Although the numbers are small given the specialized nature of pediatric orthopaedic surgery, this study has uncovered some initial gender differences regarding practice characteristics and job opportunities among pediatric orthopaedic surgeons. As more men plan to reduce their workload or retire in the next 5 years, there may be further increases in the percentage of women surgeons in the workforce, so it is important that we begin to understand what effect, if any, gender has on practice patterns, job selection, and opportunities. Also, the finding that among the new graduates more women than men are choosing careers in academic practice over private practice suggests an extraordinary opportunity to develop more female leaders and role models at major pediatric orthopaedic centers.

Geographic Trends in the Plastic Surgery Match.

BACKGROUND: The integrated plastic surgery match is among the most competitive residency matches in recent years. Although previous studies have correlated applicant characteristics with successful match outcomes, none have comprehensively investigated the role of geography in the match. This study elucidates regional biases in the match. METHODS: Plastic surgery residents who matched during 2011-2015 were eligible for study inclusion. Names of residents were obtained from official residency program websites and cross-referenced with data obtained from the Student Doctor Network. For each resident, region of residency program and medical school were compared. RESULTS: From 67 programs, 622 residents were identified. Most graduated from US medical schools (97.9%). A total of 94 residents matched at a home institution (15.1%). Half of the residents matched in the same region as their medical school (48.9%). Programs in the South matched the greatest number of residents from the same region (60.8%), whereas West programs matched the least (30.8%, p < 0.001). No regional differences existed regarding residents matching at their home institution (p = 0.268). More women matched at West programs (43.1%) versus East programs (30.6%, p < 0.05). CONCLUSIONS: A significant number of residents matched at their home institution. Roughly, half matched at a program in the same region as their medical school. Whether this regional phenomenon stems from applicant or program factors remains unknown. Yet, given the limited number of interviews and the high costs of interviewing, applicants and programs can use these data to help optimize the match process.