Promising Practices in US Sponsoring Institutions to Advance Diversity, Equity, and Inclusion in Graduate Medical Education.

Background Best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood. The Accreditation Council for Graduate Medical Education launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion award for sponsoring institutions to celebrate efforts to improve DEI in graduate medical education (GME). Objective To identify themes in practices used by award applicants to improve DEI efforts at their institutions, using a qualitative design. Methods This qualitative study employed an exploratory, inductive approach and constant comparative method to analyze award applications from 2 submission cycles (2020, 2021). Data analysis involved the use of a preliminary codebook of 29 program applications used in a previous study, which was modified and expanded, to perform a subsequent analysis of 12 sponsoring institution applications. Seven adjudication sessions were conducted to ensure coding consistency and resolve disagreements, resulting in the identification of final themes. Results Institutions' approaches to advancing DEI resulted from work within 5 themes and 10 subthemes. The themes encompassed organizational commitment (policies that reflect DEI mission), data infrastructure (tracking recruitment, retention, and inclusion efforts), community connection (service-learning opportunities), diverse team engagement (coproduction with residents), and systematic strategies for DEI support throughout the educational continuum. Consistent across themes was the importance of collaboration, avoiding silos, and the need for a comprehensive longitudinal approach to DEI to achieve a diverse GME workforce. Conclusions This qualitative study identified 5 themes that can inform and guide sponsoring institutions in promoting DEI.

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.

Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs.

Importance: Closing the diversity gap is critical to ensure equity in medical education and health care quality. Nevertheless, evidence-based strategies and best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood and underused. To improve the culture of DEI in graduate medical education (GME), in 2020 the Accreditation Council of Graduate Medical Education (ACGME) launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award to recognize exceptional DEI efforts in US residency programs. Objective: To identify strategies and best practices that exemplary US GME programs use to improve DEI. Design and Setting: This qualitative study performed an exploratory content analysis of award applications submitted to the ACGME over 2 cycles in 2020 and 2021, using the constant comparative method. The research team first acknowledged their own biases related to DEI, used caution to not overinterpret the data, and performed several cross-checks during data analysis to ensure confirmability of the results. A preliminary codebook was developed and used during regular adjudication sessions. Disagreements were discussed until agreements were reached. Main Outcomes and Measures: Foundational (ie, commonly cited, high-impact, and small-effort strategies considered achievable by all programs) and aspirational (ie, potential for high impact but requiring greater effort and investment) DEI strategies used by exemplary GME programs. Results: This qualitative study included 29 award applications submitted between August 17, 2020, and January 11, 2022. Strategies spanned the education continuum from premedical students through faculty. Foundational strategies included working with schools, community colleges, and 4-year college campuses; providing structured support for visiting students; mission-driven holistic review for admissions and selection; interviewer trainings on implicit bias mitigation and on how racism and discrimination impact admission processes and advancement; interview-day DEI strategies; inclusive selection and DEI committees; mission statements that include DEI; and retention efforts to improve faculty diversity. Aspirational strategies included development of longitudinal bidirectional collaborations (eg, articulation agreements, annual workshops, funded rotations and/or research) with organizations working with applicants who were historically excluded and underrepresented in medicine, blinding metrics in residency applications, longitudinal curricula on DEI and health equity, and faculty mentoring such as affinity groups, mentored research, and joint academic-community recruitments. Findings provide residency program leadership with a menu of options at various inflection points to foster DEI within their programs. Conclusions and Relevance: The findings of this qualitative study suggest that GME programs might adopt strategies of exemplary programs to improve DEI in residency, ensure compliance with accreditation standards, and improve health outcomes for all.

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.

Association of Marginalized Identities With Alpha Omega Alpha Honor Society and Gold Humanism Honor Society Membership Among Medical Students.

Importance: Disparities in medical student membership in Alpha Omega Alpha (AOA) are well documented. Less is known about Gold Humanism Honor Society (GHHS) membership and it remains unknown how the intersection of different identities is associated with membership in these honor societies. Objective: To examine the association between honor society membership and medical student race and ethnicity, sex, sexual orientation, socioeconomic status, and intersection of identities. Design, Setting, and Participants: This cross-sectional study analyzed data from Association of American Medical Colleges data collection instruments. The study included all students who graduated from Liaison Committee on Medical Education-accredited US medical schools from 2016 to 2019 and completed the Graduation Questionnaire. Data analysis was conducted from January 12 to July 12, 2022. Main Outcomes and Measures: Likelihood of AOA and GHHS membership by student race and ethnicity, sex, sexual orientation, childhood family income, and intersection of identities. Results: The sample of 50 384 individuals comprised 82 (0.2%) American Indian or Alaska Native, 10 601 (21.0%) Asian, 2464 (4.9%) Black, 3291 (6.5%) Hispanic, 25 (0.1%) Native Hawaiian or Pacific Islander, 30 610 (60.8%) White, 2476 (4.9%) multiracial students, and 834 (1.7%) students of other races or ethnicities. Sex and sexual orientation included 25 672 (51.0%) men and 3078 (6.1%) lesbian, gay, and bisexual (LGB). Childhood family income comprised 31 758 (60.0%) individuals with $75 000 per year or greater, 8160 (16.2%) with $50 000 to $74 999 per year, 6864 (13.6%) with $25 000 to $49 999 per year, and 3612 (7.2%) with less than $25 000 per year. The sample included 7303 (14.5%) AOA members only, 4925 (9.8%) GHHS members only, and 2384 (4.7%) members of both societies. In AOA, American Indian or Alaska Native (OR, 0.49; 95% CI, 0.25-0.96), Asian (OR, 0.49; 95% CI, 0.45-0.53), Black (OR, 0.25; 95% CI, 0.20-0.30), Hispanic (OR, 0.53; 95% CI, 0.47-0.59), multiracial (OR, 0.69; 95% CI, 0.62-0.77), and other race and ethnicity (OR, 0.73; 95% CI, 0.60-0.88) were underrepresented compared with White students; LGB students (OR, 0.75; 95% CI, 0.67-0.83) were underrepresented compared with heterosexual students; and childhood family income $50 000 to $74 999 (OR, 0.81; 95% CI, 0.75-0.86), $25 000 to $49 999 (OR, 0.68; 95% CI, 0.62-0.74), and less than $25 000 (OR, 0.60; 95% CI, 0.53-0.69) were underrepresented compared with greater than or equal to $75 000. In GHHS, Asian students (OR, 0.80; 95% CI, 0.73-0.87) were underrepresented compared with White students, female students (OR, 1.55; 95% CI, 1.45-1.65) were overrepresented compared with male students, LGB students (OR, 1.36; 95% CI, 1.23-1.51) were overrepresented compared with heterosexual students, and students with childhood family income $25 000 to $49 999 (OR, 0.85; 95% CI, 0.78-0.94) and less than $25 000 (OR, 0.75; 95% CI, 0.66-0.86) were underrepresented compared with those with greater than or equal to $75 000. Likelihood of AOA, but not GHHS, membership decreased as number of marginalized identities increased. Conclusions and Relevance: In this cross-sectional study of US medical students, membership disparities were noted in both AOA and GHHS. However, differences in GHHS existed across fewer identities, sometimes favored the marginalized group, and were not cumulative.

Association of Sociodemographic Characteristics With US Medical Student Attrition.

Importance: Diversity in the medical workforce is critical to improve health care access and achieve equity for resource-limited communities. Despite increased efforts to recruit diverse medical trainees, there remains a large chasm between the racial and ethnic and socioeconomic composition of the patient population and that of the physician workforce. Objective: To analyze student attrition from medical school by sociodemographic identities. Design, Setting, and Participants: This retrospective cohort study included allopathic doctor of medicine (MD)-only US medical school matriculants in academic years 2014-2015 and 2015-2016. The analysis was performed from July to September 2021. Main Outcomes and Measures: The main outcome was attrition, defined as withdrawal or dismissal from medical school for any reason. Attrition rate was explored across 3 self-reported marginalized identities: underrepresented in medicine (URiM) race and ethnicity, low income, and underresourced neighborhood status. Logistic regression was assessed for each marginalized identity and intersections across the 3 identities. Results: Among 33 389 allopathic MD-only medical school matriculants (51.8% male), 938 (2.8%) experienced attrition from medical school within 5 years. Compared with non-Hispanic White students (423 of 18 213 [2.3%]), those without low income (593 of 25 205 [2.3%]), and those who did not grow up in an underresourced neighborhood (661 of 27 487 [2.4%]), students who were URiM (Hispanic [110 of 2096 (5.2%); adjusted odds ratio (aOR), 1.41; 95% CI, 1.13-1.77], non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander [13 of 118 (11.0%); aOR, 3.20; 95% CI, 1.76-5.80], and non-Hispanic Black/African American [120 of 2104 (5.7%); aOR, 1.41; 95% CI, 1.13-1.77]), those who had low income (345 of 8184 [4.2%]; aOR, 1.33; 95% CI, 1.15-1.54), and those from an underresourced neighborhood (277 of 5902 [4.6%]; aOR, 1.35; 95% CI, 1.16-1.58) were more likely to experience attrition from medical school. The rate of attrition from medical school was greatest among students with all 3 marginalized identities (ie, URiM, low income, and from an underresourced neighborhood), with an attrition rate 3.7 times higher than that among students who were not URiM, did not have low income, and were not from an underresourced neighborhood (7.3% [79 of 1086] vs 1.9% [397 of 20 353]; P < .001). Conclusions and Relevance: This retrospective cohort study demonstrated a significant association of medical student attrition with individual (race and ethnicity and family income) and structural (growing up in an underresourced neighborhood) measures of marginalization. The findings highlight a need to retain students from marginalized groups in medical school.

Reflect and Reset: Black Academic Voices Call the Graduate Medical Education Community to Action.

The COVID-19 pandemic highlighted the great achievements that the biomedical community can accomplish, but raised the question: Can the same medical community that developed a complex vaccine in less than a year during a pandemic help to defeat social injustice and ameliorate the epidemic of health inequity? In this article, the authors, a group of Black academics, call on the graduate medical education (GME) community to reset its trajectory toward solutions for achieving diversity, improving inclusion, and combating racism using education as the new vector. Sponsoring institutions, which include universities, academic medical centers, teaching hospitals, and teaching health centers, are the center of the creation and dissemination of scholarship. They are often the main sources of care for many historically marginalized communities. The GME learning environment must provide the next generation of medical professionals with an understanding of how racism continues to have a destructive influence on health care professionals and their patients. Residents have the practical experience of longitudinal patient care, and a significant portion of an individual's professional identity is formed during GME; therefore, this is a key time to address explicit stereotyping and to identify implicit bias at the individual level. The authors propose 3 main reset strategies for GME-incorporating inclusive pedagogy and structural competency into education, building a diverse and inclusive learning environment, and activating community engagement-as well as tactics that sponsoring institutions can adapt to address racism at the individual learner, medical education program, and institutional levels. Sustained, comprehensive, and systematic implementation of multiple tactics could make a significant impact. It is an academic and moral imperative for the medical community to contribute to the design and implementation of solutions that directly address racism, shifting how resident physicians are educated and modeling just and inclusive behaviors for the next generation of medical leaders.

Promoting Diversity, Equity, and Inclusion in the Selection of Obstetrician-Gynecologists.

In the setting of long-standing structural racism in health care, it is imperative to highlight inequities in the medical school-to-residency transition. In obstetrics and gynecology, the percentage of Black residents has decreased in the past decade. The etiology for this troubling decrease is unknown, but racial and ethnic biases inherent in key residency application metrics are finally being recognized, while the use of these metrics to filter applicants is increasing. Now is the time for action and for transformational change to rectify the factors that are detrimentally affecting the racial diversity of our residents. This will benefit our patients and learners with equitable health care and better outcomes.

Anticipating the Impact of the USMLE Step 1 Pass/Fail Scoring Decision on Underrepresented-in-Medicine Students.

Three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have assumed an outsized role in residency selection decisions, creating intense pressure for medical students to obtain a high score on this exam. In February 2020, the Federation of State Medical Boards and the National Board of Medical Examiners announced that Step 1 would transition to pass/fail scoring beginning in 2022.The authors discuss the potential advantages and disadvantages of the pass/fail scoring change for underrepresented-in-medicine (UiM) trainees. UiM students may benefit from this change because it reduces the effect of an inequitable exam; helps correct for students who attend medical schools with a curriculum heavier on nontested formative elements; and decreases stress, improves quality of life, and undermines imposter syndrome. However, this change may also precipitate unforeseen challenges, such as increased discrimination toward UiM trainees, an increase in high-stakes test failures due to a reduced focus on preparing for standardized exams, or the development of new (e.g., subject exams) or overreliance on existing (e.g., school ranking) metrics that would make UiM residency candidates less competitive.To enhance UiM representation in the future health care workforce, it is imperative that national organizations (e.g., accrediting, licensing, regulatory, professional, honor, student, and faculty), hospitals, residency programs, and patient advocacy groups undertake a shared, rigorous approach in assessing the impact of the pass/fail scoring change on UiM applicants' selection to specialty and subspecialty residencies.