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.

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.

Changing Faces: Factors Associated with the Intention to Pursue Plastic Surgery and Practice in Underserved Areas.

Improving the number of plastic and reconstructive surgeons who provide care to patients in underserved communities is critical to achieving health equity. We aimed to identify factors associated with graduating medical students' intentions to pursue plastic surgery and practice in underserved areas. Methods: De-identified data for US medical school graduates were obtained from the Association of American Medical Colleges for students who matriculated in academic years 2007-2008 and 2011-2012. Data collected included self-reported demographic and future practice intentions. Multivariate analysis was conducted to determine indicators of students' interest in plastic surgery, and their intention to practice in underserved areas. Results: Of the 57,307 graduating US medical students in our cohort who completed the Graduation Questionnaire, 532 (0.9%) reported an intention to pursue plastic surgery. Hispanic [adjusted odds ratio (aOR): 1.45; 95% confidence interval (95% CI), 1.07-1.98] and multiracial (aOR: 1.59; 95% CI, 1.03-2.45) students were more likely to pursue plastic surgery compared with other surgical specialties. Among students interested in plastic surgery, compared with non-Hispanic White students, Black (aOR: 6.15; 95% CI, 1.96-19.26) students were more likely to report intention to practice in underserved areas. Students with community-engagement experiences were more likely to report intention to practice in underserved areas. Conclusions: Diversity among medical trainees pursuing plastic and reconstructive surgery is critical for maintaining and expanding plastic surgery services rendered in underserved areas. These findings suggest that student demographics and experiences with community-engagement experiences are positive indicators of practicing in underserved communities.

Medical student intentions to practice internal medicine in underserved areas associated with debt, identity and extracurricular participation.

BACKGROUND: Currently, Internal Medicine (IM) physicians do not reflect the ethno-racial diversity of the US population. Moreover, there is a shortage of IM physicians in Medically Underserved Areas (MUAs) in the US. The purpose of this study was to determine factors that influence medical students' intent to practice IM in MUAs. We hypothesized students with intentions to pursue a career in IM and work in MUAs were more likely than their peers to identify as underrepresented in medicine (URiM), report greater student debt loads, and report medical school experiences in cultural competencies. METHODS: We analyzed de-identified data of 67,050 graduating allopathic medical students who completed the Association of American Medical Colleges' (AAMC) Medical School annual Graduation Questionnaire (GQ) between 2012-2017 by multivariate logistic regression models, examining intent to practice IM in MUAs based on respondent characteristics. RESULTS: Of 8,363 students indicating an intent to pursue IM, 1,969 (23.54%) students also expressed an intent to practice in MUAs. Students awarded scholarships, (aOR: 1.23, [1.03-1.46]), with debt greater than $300,000 (aOR: 1.54, [1.21-1.95], and self-identified non-Hispanic Black/African American (aOR: 3.79 [2.95-4.87]) or Hispanic (aOR: 2.53, [2.05-3.11]) students were more likely than non-Hispanic White students to indicate intent to practice in MUAs. This pattern also existed for students who participated in a community-based research project (aOR: 1.55, [1.19-2.01]), had experiences related to health disparities (aOR: 2.13, [1.44-3.15]), or had experiences related to global health (aOR: 1.75, [1.34-2.28]). CONCLUSIONS: We identified experiences and characteristics that associate with intention to practice IM in MUAs, which can aid future curricular redesign by medical schools to expand and deepen comprehension of health disparities, access to community-based research, and global health experiences. Loan forgiveness programs and other initiatives to increase recruitment and retention of future physicians should also be developed.

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.

Rates of National Institutes of Health Funding for Surgeon-Scientists, 1995-2020.

Importance: Surgeon-scientists are uniquely positioned to facilitate translation between the laboratory and clinical settings to drive innovation in patient care. However, surgeon-scientists face many challenges in pursuing research, such as increasing clinical demands that affect their competitiveness to apply for National Institutes of Health (NIH) funding compared with other scientists. Objective: To examine how NIH funding has been awarded to surgeon-scientists over time. Design, Setting, and Participants: This cross-sectional study used publicly available data from the NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results) database for research project grants awarded to departments of surgery between 1995 and 2020. Surgeon-scientists were defined as NIH-funded faculty holding an MD or MD-PhD degree with board certification in surgery; PhD scientists were NIH-funded faculty holding a PhD degree. Statistical analysis was performed from April 1 to August 31, 2022. Main Outcome: National Institutes of Health funding to surgeon-scientists compared with PhD scientists, as well as NIH funding to surgeon-scientists across surgical subspecialties. Results: Between 1995 and 2020, the number of NIH-funded investigators in surgical departments increased 1.9-fold from 968 to 1874 investigators, corresponding to a 4.0-fold increase in total funding (1995, $214 million; 2020, $861 million). Although the total amount of NIH funding to both surgeon-scientists and PhD scientists increased, the funding gap between surgeon-scientists and PhD scientists increased 2.8-fold from a $73 million difference in 1995 to a $208 million difference in 2020, favoring PhD scientists. National Institutes of Health funding to female surgeon-scientists increased significantly at a rate of 0.53% (95% CI, 0.48%-0.57%) per year from 4.8% of grants awarded to female surgeon-scientists in 1995 to 18.8% in 2020 (P < .001). However, substantial disparity remained, with female surgeon-scientists receiving less than 20% of NIH grants and funding dollars in 2020. In addition, although there was increased NIH funding to neurosurgeons and otolaryngologists, funding to urologists decreased significantly from 14.9% of all grants in 1995 to 7.5% in 2020 (annual percent change, -0.39% [95% CI, -0.47% to -0.30%]; P < .001). Despite surgical diseases making up 30% of the global disease burden, representation of surgeon-scientists among NIH investigators remains less than 2%. Conclusion and Relevance: This study suggests that research performed by surgeon-scientists continues to be underrepresented in the NIH funding portfolio, highlighting a fundamental need to support and fund more surgeon-scientists.

Temporal Trends in Childhood Household Income Among Applicants and Matriculants to Medical School and the Likelihood of Acceptance by Income, 2014-2019.

This study examines trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income.

Gender Disparity in National Institutes of Health Funding Among Surgeon-Scientists From 1995 to 2020.

Importance: Surgical diseases account for approximately 30% of the global burden of disease. Gender diversity in biomedical research is critical to generate innovative patient-centered research in surgery. Objective: To examine the distribution of biomedical research funding by the National Institutes of Health (NIH) among women and men surgeon-scientists during a 25-year period. Design, Setting, and Participants: This cross-sectional study used publicly available data from the NIH RePORTER (Research Portfolio Online Reporting Tools: Expenditures and Results) database for research project grants awarded to women and men surgeon-scientists who were principal investigators between 1995 and 2020. Data were retrieved between January 20 and March 20, 2022. The representation of women surgeon-scientists among academic surgeons was compared with the representation of men surgeon-scientists over time. Main Outcomes and Measures: Distribution of NIH funding to women and men surgeon-scientists was examined via 2 metrics: holding a large-dollar (ie, R01-equivalent) grant and being a super principal investigator (SPI) with $750 000 or more in total annual research funding. Statistical analysis was performed between April 1 and August 31, 2022. Results: Between 1995 and 2020, 2078 principal investigator surgeons received funding from the NIH. The proportion of women academic surgeons who were surgeon-scientists remained unchanged during this same period (1995, 14 of 792 [1.8%] vs 2020, 92 of 3834 [2.4%]; P = .10). Compared with their men counterparts, women surgeon-scientists obtained their first NIH grant earlier in their career (mean [SD] years after first faculty appointment, 8.8 [6.2] vs 10.8 [7.9] years; P < .001) and were as likely to obtain large-dollar grants (aRR, 0.99 [95% CI, 0.95-1.03]) during the period 2016 to 2020. Despite this success, women surgeon-scientists remained significantly underrepresented among SPIs and were 25% less likely to be an SPI (aRR, 0.75 [95% CI, 0.60-0.95] during the period 2016 to 2020). Conclusions and Relevance: The findings of this cross-sectional study of NIH-funded surgeons suggest that women surgeons remained underrepresented among surgeon-scientists over a 25-year period despite early career success in receiving NIH funding. This is concerning and warrants further investigation to increase the distribution of NIH funding among women surgeon-scientists.

Revolutionizing Health Professions Admissions to Achieve an Inclusive Workforce.

This article describes the "The Admissions Revolution: Bold Strategies for Diversifying the Healthcare Workforce" conference, which preceded the 2022 Beyond Flexner Alliance Conference and called for health professions institutions to boldly reimagine the admission process to diversify the health care workforce. Proposed strategies encompassed 4 key themes: admission metrics, aligning admission practices with institutional mission, community partnerships to fulfill social mission, and student support and retention. Transformation of the health professions admission process requires broad institutional and individual effort. Careful consideration and implementation of these practices will help institutions achieve greater workforce diversity and catalyze progress toward health equity.

Gender, Racial, and Ethnic and Inequities in Receipt of Multiple National Institutes of Health Research Project Grants.

Importance: Diversity in the biomedical research workforce is essential for addressing complex health problems. Female investigators and investigators from underrepresented ethnic and racial groups generate novel, impactful, and innovative research, yet they are significantly underrepresented among National Institutes of Health (NIH) investigators. Objective: To examine the gender, ethnic, and racial distribution of super NIH investigators who received 3 or more concurrent NIH grants. Design, Setting, and Participants: This cross-sectional study included a national cohort of NIH-funded principal investigators (PIs) from the NIH Information for Management, Planning, Analysis, and Coordination (IMPAC II) database from 1991 to 2020. Exposures: Self-identified gender, race and ethnicity, annual number of NIH grant receipt, career stage, and highest degree. Main Outcomes and Measures: Distribution of investigators receiving 3 or more research project grants, referred to as super principal investigators (SPIs), by gender, race, and ethnicity. Results: Among 33 896 investigators in fiscal year 2020, 7478 (22.01%) identified as Asian, 623 (1.8%) as Black, 1624 (4.8%) as Hispanic, and 22 107 (65.2%) as White; 21 936 (61.7%) identified as men; and 8695 (35.3%) were early-stage investigators. Between 1991 and 2020, the proportion of SPIs increased 3-fold from 704 (3.7%) to 3942 (11.3%). However, SPI status was unequal across gender, ethnic, and racial groups. Women and Black PIs were significantly underrepresented among SPIs, even after adjusting for career stage and degree, and were 34% and 40% less likely than their male and White colleagues, respectively, to be an SPI. Black women PIs were the least likely to be represented among SPIs and were 71% less likely to attain SPI status than White men PIs (adjusted odds ratio, 0.29; 95% CI, 0.21-0.41). Conclusions and Relevance: In this cross-sectional study of a national cohort of NIH-funded investigators, the gender, ethnic, and racial gaps in receipt of multiple research project grants among NIH investigators was clearly apparent and warrants further investigation and interventions.

Racial and Ethnic Differences in Internal Medicine Residency Assessments.

Importance: Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education. Objective: To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents. Design, Setting, and Participants: This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022. Main Outcomes and Measures: The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes. Results: The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training. Conclusions and Relevance: In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

Inequity in National Institutes of Health Predoctoral Fellowships, 2001-2020.

This cross-sectional study examines trends in number of awards and funding of general and diversity F31 predoctoral fellowships from 2001 to 2020.

Characteristics of graduating medical students interested in neurosurgery with intention to practice in underserved areas: Implications for residency programs.

OBJECTIVE: It is of paramount importance that the United States (U.S.) physician and surgical workforce reflects its changing population demographics. The authors characterized factors contributing to graduating medical students' decision to pursue a residency in Neurosurgery to assess opportunities for recruitment and retainment of graduates interested in working with underserved populations. METHODS: Data from the Association of American Medical Colleges (AAMC) Student Record System (SRS), and the AAMC Graduation Questionnaire (GQ) were collected on a national cohort of U.S. medical students from 2012 through 2017. Data including self-reported sex, race/ethnicity, age at matriculation, degree program, intention to practice in underserved area, total debt, scholarships, volunteer activities and medical electives was analyzed using chi-squared tests and multivariate logistic regression models. RESULTS: The study included 48,096 graduating medical students surveyed by GQ and SRS, 607 (1.26%) of whom reported an intention to pursue Neurosurgery (Neurosurgery cohort). Compared to students pursuing other specialties, the Neurosurgery cohort had fewer students identify as female (18.95% vs. 48.18%, p < 0.001), and report an intention to work with underserved populations (11.37% vs. 26.37%, p < 0.001). In addition, Black/African-American students were significantly more like to indicate intention to pursue Neurosurgery compared to White students (aOR=1.51, 95% CI:1.01-2.24). Moreover, within the Neurosurgery cohort, Black/African-American (aOR=7.66, 95% CI:2.87-20.45), Hispanic (aOR=4.50, 95% CI:1.40-14.51) and female students (aOR=2.44, 95% CI:1.16-5.12) were more likely to report an intention to practice in underserved urban and rural areas, compared to their peers. CONCLUSIONS: Our study identified several key demographic and academic factors influencing intention to pursue a neurosurgical career, and work with underserved populations. Our data provides an opportunity for further discussions on the residency selection process and seeks to empower residency programs to diversify the neurosurgical workforce, tackle health disparities and improve patient care for the entire US population.

Identifying and Addressing Basic Needs Insecurity Among Medical Students: A Curriculum for Trainees, Administrators, and Faculty.

INTRODUCTION: Data from a 2018 United States Government Accountability Office report show that basic needs insecurity undermines the postsecondary educational experiences of many students. In recent years, basic needs insecurity among undergraduate students has gained attention in the literature, but published data regarding medical trainees are extremely limited. METHODS: A 60-minute interactive workshop consisting of a PowerPoint presentation and case discussions was created. Our aim was to increase awareness and understanding of basic needs insecurity among medical students. The workshop included a basic needs survey and national and local resource guides. The workshop was evaluated through pre- and postworkshop questionnaires. RESULTS: There were a total of 61 participants with diverse identities, including premedical and medical students, faculty, staff, and administrators. A comparison of pre- and postworkshop data showed increases in all knowledge-based questions, two of which were statistically significant. Most learners somewhat or strongly agreed the learning objectives were met. Participants positively commented on the interactive and collaborative nature of the workshop, the perspective the case discussions offered, and the tangible resources provided to them. DISCUSSION: This single session serves as a starting point to bring awareness that basic needs insecurity exists among medical trainees. It is a step toward a cross-departmental approach to assess the scope of the problem and find solutions to address it. Through the widespread implementation of this session, we hope participants can enact sustainable institutional changes that will support the basic needs of students.

Association of Demographic Factors and Medical School Experiences With Students' Intention to Pursue a Surgical Specialty and Practice in Underserved Areas.

Importance: The surgical workforce shortage is a threat to promoting health equity in medically underserved areas. Although the Health Resources and Services Administration and the American College of Surgeons have called to increase the surgical pipeline for trainees to mitigate this shortage, the demographic factors associated with students' intention to practice in underserved areas is unknown. Objective: To evaluate the association between students' demographics and medical school experiences with intention to pursue surgery and practice in underserved areas. Design, Setting, and Participants: This cross-sectional study surveyed graduating US allopathic medical students who matriculated between 2007-2008 and 2011-2012. Analysis began June 2020 and ended December 2020. Main Outcomes and Measures: Intention to pursue surgery and practice in underserved areas were retrieved from the Association of American Medical Colleges graduation questionnaire. Logistic regression models were constructed to evaluate (1) the association between demographic factors and medical students' intention to pursue surgical specialties vs medical specialties and (2) the association between demographic factors and medical school electives with intention to practice in underserved areas. Results: Among 57 307 students who completed the graduation questionnaire, 48 096 (83.9%) had complete demographic data and were included in the study cohort. The mean (SD) age at matriculation was 23.4 (2.5) years. Compared with students who reported intent to pursue nonsurgical careers, a lower proportion of students who reported intent to pursue a surgical specialty identified as female (3264 [32.4%] vs 19 731 [51.9%]; χ2 P < .001). Multiracial Black and White students (adjusted odds ratio [aOR], 1.72; 95% CI, 1.11-2.65) were more likely to report an intent for surgery compared with White students. Among students who reported an intention to pursue surgery, Black/African American students (aOR, 3.24; 95% CI, 2.49-4.22), Hispanic students (aOR, 2.00; 95% CI, 1.61-2.47), multiracial Black and White students (aOR, 2.27; 95% CI, 1.03-5.01), and Indian/Pakistani students (aOR, 1.31; 95% CI, 1.02-1.69) were more likely than White students to report an intent to practice in underserved areas. Students who reported participating in community health (aOR, 1.61; 95% CI, 1.42-1.83) or global health (aOR, 1.83; 95% CI, 1.61-2.07) experiences were more likely to report an intention to practice in underserved areas. Conclusions and Relevance: This study suggests that diversifying the surgical training pipeline and incorporating health disparity and community health in undergraduate or graduate medical education may promote students' motivation to practice in underserved areas.