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.

Community College Pathways to Medical School and Family Medicine Residency Training.

PURPOSE: Medical students who attend community college are more likely to express intention to train in family medicine. This study examined whether community college attendance is associated with family medicine residency training in a national sample of US medical school graduates. METHODS: We performed a cross-sectional analysis using the Association of American Medical Colleges matriculant files of residency trainees who graduated from medical school between 2010 to 2012. Residency specialty (family medicine vs other) was modeled using logistic regression analysis; the key independent variable was community college attendance, with categories of non-community college (reference); community college while in high school; community college after graduating from high school, then transfer to 4-year university; and community college after graduating from a 4-year university or as a postbaccalaureate. The logistic model adjusted for age, sex, race/ethnicity, years in medical school, parental education (a marker of socioeconomic status), and high school US region. RESULTS: Of the 43,382 medical school graduates studied, 25.9% attended community college and 8.7% trained in family medicine. In unadjusted analysis, graduates attending community college while in high school, after graduating from high school with transfer to 4-year university, or after graduating from a 4-year university or as a postbaccalaureate (12.0%, 12.7%, and 10.8%, respectively) were more likely to train in family medicine compared with their peers who did not attend community college (7.7%). Respective adjusted odds ratios were 1.47 (95% CI, 1.33-1.63; P <.001), 1.27 (95% CI, 1.06-1.52; P = .009), and 1.17 (95% CI, 1.06-2.29; P = .002). Among family medicine residents, 32.7% of those who were white, 35.2% of those Asian, 50.8% of those Latino, and 32.7% of those black or African American attended community college. CONCLUSIONS: US medical school graduates who attended community college were more likely to train in family medicine, suggesting community college is an important pathway for increasing the primary care workforce.

Holistic Admissions at UC Davis-Journey Toward Equity.

This Viewpoint discusses what higher education institutions can learn from UC Davis when it comes to ensuring equity for their students now that the US Supreme Court has eliminated race-conscious college admissions.

Reliability of Multiple Mini-Interviews and traditional interviews within and between institutions: a study of five California medical schools.

BACKGROUND: Many medical schools use admissions Multiple Mini-Interviews (MMIs) rather than traditional interviews (TIs), partly because MMIs are thought to be more reliable. Yet prior studies examined single-school samples of candidates completing either an MMI or TI (not both). Using data from five California public medical schools, the authors examined the within- and between-school reliabilities of TIs and MMIs. METHODS: The analyses included applicants interviewing at ≥1 of the five schools during 2011-2013. Three schools employed TIs (TI1, TI2, TI3) and two employed MMIs (MMI1, MMI2). Mixed linear models accounting for nesting of observations within applicants examined standardized TI and MMI scores (mean = 0, SD = 1), adjusting for applicant socio-demographics, academic metrics, year, number of interviews, and interview date. RESULTS: A total of 4993 individuals (completing 7516 interviews [TI = 4137, MMI = 3379]) interviewed at ≥1 school; 428 (14.5%) interviewed at both MMI schools and 687 (20.2%) at more than one TI school. Within schools, inter-interviewer consistency was generally qualitatively lower for TI1, TI2, and TI3 (Pearson's r 0.07, 0.13, and 0.29, and Cronbach's α, 0.40, 0.44, and 0.61, respectively) than for MMI1 and MMI 2 (Cronbach's α 0.68 and 0.60, respectively). Between schools, the adjusted intraclass correlation coefficient was 0.27 (95% CI 0.20-0.35) for TIs and 0.47 (95% CI 0.41-0.54) for MMIs. CONCLUSIONS: Within and between-school reliability was qualitatively higher for MMIs than for TIs. Nonetheless, TI reliabilities were higher than anticipated from prior literature, suggesting TIs may not need to be abandoned on reliability grounds if other factors favor their use.

US Medical School Admissions Leaders' Experiences With Barriers to and Advancements in Diversity, Equity, and Inclusion.

Importance: Despite decades-long calls for increasing racial and ethnic diversity, the medical profession continues to exclude members of Black or African American, Hispanic or Latinx, and Indigenous groups. Objective: To describe US medical school admissions leaders' experiences with barriers to and advances in diversity, equity, and inclusion. Design, Setting, and Participants: This qualitative study involved key-informant interviews of 39 deans and directors of admission from 37 US allopathic medical schools across the range of student body racial and ethnic composition. Interviews were conducted in person and online from October 16, 2019, to March 27, 2020, and analyzed from October 2019 to March 2021. Main Outcomes and Measures: Participant experiences with barriers to and advances in diversity, equity, and inclusion. Results: Among 39 participants from 37 medical schools, admissions experience ranged from 1 to 40 years. Overall, 56.4% of participants identified as women, 10.3% as Asian American, 25.6% as Black or African American, 5.1% as Hispanic or Latinx, and 61.5% as White (participants could report >1 race and/or ethnicity). Participants characterized diversity broadly, with limited attention to racial injustice. Barriers to advancing racial and ethnic diversity included lack of leadership commitment; pressure from faculty and administrators to overemphasize academic scores and school rankings; and political and social influences, such as donors and alumni. Accreditation requirements, holistic review initiatives, and local policy motivated reforms but may also have inadvertently lowered expectations and accountability. Strategies to overcome challenges included narrative change and revision of school leadership structure, admissions goals, practices, and committee membership. Conclusions and Relevance: In this qualitative study, admissions leaders characterized the ways in which entrenched beliefs, practices, and power structures in medical schools may perpetuate institutional racism, with far-reaching implications for health equity. Participants offered insights on how to remove inequitable structures and implement process changes. Without such action, calls for racial justice will likely remain performative, and racism across health care institutions will continue.

The Performance and Trajectory of Medical Students With Disabilities: Results From a Multisite, Multicohort Study.

PURPOSE: To conduct a post-Americans with Disabilities Act Amendments Act of 2008 multisite, multicohort study called the Pathways Project to assess the performance and trajectory of medical students with disabilities (SWDs). METHOD: From June to December 2020, the authors conducted a matched cohort study of SWDs and nondisabled controls from 2 graduating cohorts (2018 and 2019) across 11 U.S. MD-granting medical schools. Each SWD was matched with 2 controls, one from their institution and, whenever possible, one from their cohort for Medical College Admission Test score and self-reported gender. Outcome measures included final attempt Step 1 and Step 2 Clinical Knowledge scores, time to graduation, leave of absence, matching on first attempt, and matching to primary care. RESULTS: A total of 171 SWDs and 341 controls were included; the majority of SWDs had cognitive/learning disabilities (118/171, 69.0%). Compared with controls, SWDs with physical/sensory disabilities had similar times to graduation (88.6%, 95% confidence interval [CI]: 77.0, 100.0 vs 95.1%, 95% CI: 90.3, 99.8; P = .20), Step 1 scores (229.6 vs 233.4; P = .118), and match on first attempt (93.9%, 95% CI: 86.9, 100.0 vs 94.6%, 95% CI: 91.8, 97.4; P = .842), while SWDs with cognitive/learning disabilities had lower Step 1 scores (219.4; P < .001) and were less likely to graduate on time (81.2%, 95% CI: 69.2, 93.2; P = .003) and match on first attempt (85.3%, 95% CI: 78.0, 92.7; P = .009). Accommodated SWDs had Step 1 scores that were 5.9 points higher than nonaccommodated SWDs (95% CI: -0.7, 12.5; P = .08). CONCLUSIONS: Structural barriers remain for SWDs with cognitive/learning disabilities, which could be partially mitigated by accommodations on high-stakes exams.

What Does It Mean for Medical School Admissions to Be Socially Accountable?

Health care workforce diversity is a critical determinant of health equity and the social mission of medical education. Medical schools have a social contract with the public, which provides significant financial support to academic medical centers. Although a focus on diversity is critical in the admissions process for health professions schools, most US medical schools have failed to achieve racial-ethnic or economic diversity representative of the general US population. This article discusses limitations of holistic admissions, structural challenges for diverse learners in medical education, and how to implement socially accountable admissions.

Associations of Postbaccalaureate Coursework with Underrepresented Race/Ethnicity, Academic Performance, and Primary Care Training among Matriculants at Five California Medical Schools.

Studies employing data collected over 15 years ago suggested salutary effects of postbaccalaureate (PB) premedical coursework on medical school class diversity, academic performance, and primary care training. The studies may have limited current applicability given changes in medical school admissions paradigms and population demographics. Using data from interviewees at >1 of 5 California public medical schools between 2011-2013 (N=3805), we examined associations of PB premedical coursework with underrepresented race/ethnicity; academic performance (United States Medical Licensing Examination Step 1 and Step 2 scores, clerkship Honors); and primary care residency. Adjusting for age, sex, and year, PB coursework was associated with underrepresented race/ethnicity, but not after further adjustment for self-designated disadvantage (SDA). PB coursework was not associated with academic performance or primary care residency. Holistic consideration of SDA and UIM status in admissions coupled with robust matriculant support may merit exploration as an alternative to PB coursework for increasing medical school diversity.

A multi-institutional survey of internal medicine residents' learning habits.

BACKGROUND: Resident physicians are expected to demonstrate medical knowledge. However, little is known about the residents' reading habits and learning preferences. AIM: To assess residents' reading habits and preferred educational resources. METHODS: Residents at five internal medicine training programs were surveyed regarding their reading and learning habits and preferences. RESULTS: The majority (77.7%) of residents reported reading less than 7 h a week. Most residents (81.4%) read in response to patient care encounters. The preferred educational format was electronic; 94.6% of residents cited UpToDate as the most effective resource for knowledge acquisition, and 88.9% of residents reported that UpToDate was their first choice for answering clinical questions. CONCLUSIONS: Residents spent little time reading and sought knowledge primarily from electronic resources. Most residents read in the context of patient care. Future research should focus on strategies for helping resident physicians learn in the electronic age.

The Relationships among Self-Designated Disadvantage, Socioeconomic Disadvantage, and Academic Performance in Medical School: A Multi-Institutional Study.

As medical schools seek to address the growing disparity between the socioeconomic makeup of their students and the general population, it is important to understand the academic trajectory of disadvantaged students. We used a locally-developed multicomponent socioeconomic disadvantage (SED) measure and the self-designated disadvantaged (SDA) question ["yes" (+) or "no" (-)] from the American Medical College Application Service application to examine academic performance of students from three disadvantaged categories (high SED/SDA+, high SED/SDA-, and low SED/SDA+); with low SED/SDA-as the reference group across five California schools. Compared with reference, the DA+ subgroups scored lower on USMLE Step 1 and Step 2 Clinical Knowledge examinations and received fewer clerkship Honors. After adjustment for academic metrics and sociodemographic variables, high SED subgroups performed similarly to reference, but performance gaps for low SED/SDA+ students persisted. Medical schools must better understand the institutional and other drivers of academic success in disadvantaged students.

Medical Student Socioeconomic Disadvantage, Self-Designated Disadvantage, and Subsequent Academic Performance.

We previously reported that medical school matriculants with higher scores on a continuous measure of socioeconomic disadvantage (SED) had worse academic performance than those with lower scores. Analyses examining performance concurrently by SED and self-designated disadvantage (SDA) are lacking, an important gap since SDA may reflect perceptions only partly shaped by SED. We examined the associations of the four possible combinations of SED and SDA categories-SED+/SDA+, SED+/SDA-, and SED-/SDA+ (versus SED-/SDA-as reference)-with U.S. Medical Licensing Examination (USMLE) Step 1 and 2 Clinical Knowledge performance and third-year clerkship Honors at one medical school. USMLE scores were lower than reference for SED+/SDA+ and SED-/SDA+ (but not SED+/SDA-) students. SED+/SDA+, SED+/SDA-, and SED-/SDA+ students all received fewer Honors than reference. The findings indicate SED and SDA each predict different features of medical school performance, suggesting avenues for enhancing disadvantaged students' success and the representativeness of the physician workforce.