Leave of Absence and Medical Student Placement Into Graduate Medical Education by Race and Ethnicity.

This study examines the association between taking a leave of absence from medical school and placement into graduate medical education (GME) by race and ethnicity.

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.

Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity With Sustained and Cultivated Careers in Surgery.

OBJECTIVE: Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS: This retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS: Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery [adjusted relative risk (aRR): 0.92 (0.85-0.98)], while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates. CONCLUSIONS AND RELEVANCE: This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.

Association of Racial and Ethnic Identity With Attrition From MD-PhD Training Programs.

This cohort study analyzes the attrition rates of students from MD-PhD training programs by race and ethnicity.

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.

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.

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.

Sex Differences in Symptom Complexity and Door-to-Balloon Time in Patients With ST-Elevation Myocardial Infarction.

Greater symptom complexity in women than in men could slow acute ST-elevation myocardial infarction (STEMI) recognition and delay door-to-balloon (D2B) times. We sought to determine the sex differences in symptom complexity and their relation to D2B times in 1,677 young and older patients with STEMI using data from the VIRGO and SILVER-AMI studies. Symptom complexity was defined by the number of symptom patterns or phenotypes and average number of symptoms. The numbers of symptom phenotypes were compared in women and men using the Monte Carlo permutation testing. Groups were also compared using the generalized linear regression and logistic regression. The number of symptom phenotypes (244 vs 171, p = 0.02), mean number of symptoms (4.7 vs 4.2, p <0.001), and mean D2B time (114.6 vs 97.8 minutes, p = 0.004) were greater in young women than in young men but were not significantly different in older women compared with older men. The regression analysis did not show a relation between symptom complexity and D2B time overall; although, chest pain was a significant predictor of D2B times, and young women were more likely to report symptoms other than chest pain. Among patients with STEMI, 36% did not receive percutaneous coronary intervention (PCI), which was associated with presentation delay >6 hours. In patients with STEMI with either D2B time ≥90 minutes or no PCI, women had significantly more symptom phenotypes overall and in VIRGO but not in SILVER-AMI. In conclusion, the markers of symptom complexity were not associated with D2B time overall, but more symptom phenotypes in young women were associated with prolonged D2B time or no PCI. In addition, greater frequency of nonchest pain symptoms in young women may have also slowed the recognition of STEMI and D2B times in young women. Further research on symptoms clusters is needed to improve the recognition of STEMIs to improve the D2B times in young women.

Residency Program Directors' Views on Research Conducted During Medical School: A National Survey.

PURPOSE: With the United States Medical Licensing Examination Step 1 transition to pass/fail in 2022, uncertainty exists regarding how other residency application components, including research conducted during medical school, will inform interview and ranking decisions. The authors explore program director (PD) views on medical student research, the importance of disseminating that work, and the translatable skill set of research participation. METHOD: Surveys were distributed to all U.S. residency PDs and remained open from August to November 2021 to query the importance of research participation in assessing applicants, whether certain types of research were more valued, productivity measures that reflect meaningful research participation, and traits for which research serves as a proxy. The survey also queried whether research would be more important without a numeric Step 1 score and the importance of research vs other application components. RESULTS: A total of 885 responses from 393 institutions were received. Ten PDs indicated that research is not considered when reviewing applicants, leaving 875 responses for analysis. Among 873 PDs (2 nonrespondents), 358 (41.0%) replied that meaningful research participation will be more important in offering interviews. A total of 164 of 304 most competitive specialties (53.9%) reported increased research importance compared with 99 of 282 competitive (35.1%) and 95 of 287 least competitive (33.1%) specialties. PDs reported that meaningful research participation demonstrated intellectual curiosity (545 [62.3%]), critical and analytical thinking skills (482 [55.1%]), and self-directed learning skills (455 [52.0%]). PDs from the most competitive specialties were significantly more likely to indicate that they value basic science research vs PDs from the least competitive specialties. CONCLUSIONS: This study demonstrates how PDs value research in their review of applicants, what they perceive research represents in an applicant, and how these views are shifting as the Step 1 exam transitions to pass/fail.

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.

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.

A risk model for decline in health status after acute myocardial infarction among older adults.

BACKGROUND: Health status is increasingly recognized as an important patient-centered outcome after acute myocardial infarction (AMI). Yet drivers of decline in health status after AMI remain largely unknown in older adults. We sought to develop and validate a predictive risk model for health status decline among older adult survivors of AMI. METHODS: Using data from a prospective cohort study conducted from 2013 to 2017 of 3041 patients age ≥75 years hospitalized with acute myocardial infarction at 94 U.S. hospitals, we examined a broad array of demographic, clinical, functional, and psychosocial variables for their association with health status decline, defined as a decrease of ≥5 points in the Short Form-12 (SF-12) physical component score from hospitalization to 6 months post-discharge. Model selection was performed in logistic regression models of 20 imputed datasets to yield a parsimonious risk prediction model. Model discrimination and calibration were evaluated using c-statistics and calibration plots, respectively. RESULTS: Of the 2571 participants included in the main analyses, 30% of patients experienced health status decline from hospitalization to 6 months post-discharge. The risk model contained 14 factors, 10 associated with higher risk of health status decline (age, pre-existing AMI, pre-existing cancer, pre-existing COPD, pre-existing diabetes, history of falls, presenting Killip class, acute kidney injury, baseline health status, and mobility impairment) and four associated with lower risk of health status decline (male sex, higher hemoglobin, receipt of revascularization, and arrhythmia during hospitalization). The model displayed good discrimination (c-statistic = 0.74 in validation cohort) and calibration (p > 0.05) in both development and validation cohorts. CONCLUSIONS: We used split sampling to develop and validate a risk model for health status decline in older adults after hospitalization for AMI and identified several risk factors that may be modifiable to mitigate the threat of this important patient-centered outcome. External validation of this risk model is warranted.

Racial disparities among older adults with acute myocardial infarction: The SILVER-AMI study.

BACKGROUND: Despite an aging population, little is known about racial disparities in aging-specific functional impairments and mortality among older adults hospitalized for acute myocardial infarction (AMI). METHODS: We analyzed data from patients aged 75 years or older who were hospitalized for AMI at 94 US hospitals from 2013 to 2016. Functional impairments and geriatric conditions were assessed in-person during the AMI hospitalization. The association between race and risk of mortality (primary outcome) was evaluated with logistic regression adjusted sequentially for age, clinical characteristics, and measures of functional impairment and other conditions associated with aging. RESULTS: Among 2918 participants, 2668 (91.4%) self-identified as White and 250 (8.6%) as Black. Black participants were younger (80.8 vs 81.7 years; p = 0.010) and more likely to be female (64.8% vs 42.5%; p < 0.001). Black participants were more likely to present with impairments in cognition (37.6% vs 14.5%; p < 0.001), mobility (66.0% vs 54.6%; p < 0.001) and vision (50.1% vs 35.7%; p < 0.001). Black participants were also more likely to report a disability in one or more activities of daily living (22.4% vs 13.0%; p < 0.001) and an unintentional loss of more than 10 lbs in the year prior to hospitalization (37.2% vs 13.0%; p < 0.001). The unadjusted odds of 6-month mortality among Black participants (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4-2.8) attenuated to non-significance after adjustment for age, clinical characteristics (OR 1.70, 95% CI 1.7, 1.2-2.5), and functional/geriatric conditions (OR 1.5, 95% CI 1.0-2.2). CONCLUSIONS: Black participants had a more geriatric phenotype despite a younger average age, with more functional impairments. Controlling for functional impairments and geriatric conditions attenuated disparities in 6-month mortality somewhat. These findings highlight the importance of systematically assessing functional impairment during hospitalization and also ensuring equitable access to community programs to support post-AMI recovery among Black older adults.

National Institutes of Health Diversity Supplement Awards by Medical School.

BACKGROUND: Increasing medical school faculty diversity is an urgent priority. National Institutes of Health (NIH) diversity supplements, which provide funding and career development opportunities to individuals underrepresented in research, are an important mechanism to increase faculty diversity. OBJECTIVE: Analyze diversity supplement utilization by medical schools. DESIGN: Retrospective cohort study. PARTICIPANTS: All R01 grant-associated diversity supplements awarded to medical schools from 2005 to 2020. Diversity supplements were identified using the publicly available NIH RePORTER database. MAIN MEASURES: Main measures were the number of R01-associated diversity supplements awarded to medical schools each year by medical school NIH funding status and the number of R01-associated diversity supplements awarded to individual medical schools in the NIH top 40 by funding status. We also examined the percentage of R01 grants with an associated diversity supplement by NIH funding status and individual medical school in the NIH top 40. KEY RESULTS: From 2005 to 2020, US medical school faculty received 1389 R01-associated diversity supplements. The number of diversity supplements awarded grew from 2012 to 2020, from ten to 187 for top 40 schools, and from seven to 83 for non-top 40 schools. The annual growth rate for diversity supplement awards at NIH top 40 schools (44.2%) was not significantly different than the annual growth rate among non-top 40 schools (36.2%; p = 0.68). From 2005 to 2020, the highest number of diversity supplements that an individual medical school received was 56 and the lowest number was four (mean = 24.6, SD = 11.7). The highest percentage of R01 grants with an associated diversity supplement received by a school was 4.5% and the lowest percentage was 0.79% (mean = 2.3%, SD = 0.98). CONCLUSION: Medical schools may be missing an opportunity to address the continuing shortage of individuals historically underrepresented in biomedical science and should consider additional mechanisms to enhance diversity supplement utilization.

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.

Variation in Research Experiences and Publications During Medical School by Sex and Race and Ethnicity.

Importance: Diverse research teams are critical to solving complex health problems and producing high-quality medical research. Objective: To examine the associations of student sex and racial and ethnic identity with publication rates during medical school. Design, Setting, and Participants: This cohort study assessed individual-level data of US MD graduates from medical school who matriculated in academic years 2014 to 2015 and 2015 to 2016. Data were obtained from the Association of American Medical Colleges and analyzed from October 2021 to January 2022. Main Outcomes and Measures: Outcomes of interest included students' self-reported participation in unique research experiences, number of publications, and computed publications per research experience. Poisson regressions were constructed to determine the association of sex and racial and ethnic identity with research outcomes using adjusted rate ratios (aRRs). Results: Among 31 474 graduates, 15 159 (48.2%) identified as women and 4344 (13.8%) identified as underrepresented in medicine by race and ethnicity (URIM; including American Indian, Alaska Native, Black, Hawaiian Native, Hispanic/Latinx, and Pacific Islander individuals). Students who attended National Institutes of Health (NIH) top 40 research-ranked schools reported higher number of research experiences and publication counts, resulting in a higher publication rate compared with students from non-top 40 schools (median [IQR] 1.60 [1.00-3.00] vs 1.25 [0.50-2.33]; P < .001). Women reported a higher number of research experiences than men but a significantly lower number of publications (top 40 schools: aRR, 0.89; 95% CI, 0.87-0.90; non-top 40 schools: aRR, 0.93; 95% CI, 0.92-0.95). This resulted in a significantly lower publication rate among women (top 40 schools: aRR, 0.85; 95% CI, 0.83-0.86; non-top 40 schools: aRR, 0.91; 95% CI, 0.90-0.92). Compared with White students, Asian students had higher publication rates at both NIH top 40 schools (aRR, 1.10; 95% CI, 1.08-1.12) and non-top 40 schools (aRR, 1.07; 95% CI, 1.05-1.08), while lower publication rates were reported among Black students (top 40 schools: aRR, 0.83; 95% CI, 0.80-0.86; non-top 40 schools: aRR, 0.88; 95% CI, 0.85-0.95) and Hispanic students attending non-top 40 schools (aRR, 0.93; 95% CI, 0.90-0.95). Conclusions and Relevance: These findings illustrate that inequities in the physician-scientist workforce began early in training and highlight key areas for intervention, such as funding support and mentorship training during undergraduate medical education, that may promote the future success of a diverse physician-scientist workforce.

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.

Associations between hospitalist physician workload, length of stay, and return to the hospital.

BACKGROUND: Hospitalist physicians' workload-the total number of patients they care for daily-is rising in the U.S. Hospitalists report that increased workload negatively affects patients care. OBJECTIVE: Measure the associations between hospitalist physicians' workload and clinical outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: Observational study, using electronic health record (EHR) data, of adults hospitalized on the hospitalist service at Yale-New Haven Hospital from 2015-2018. MAIN OUTCOME AND MEASURES: We defined hospitalists' workload as the number of patients they cared for on the first full hospital day of a given patient's encounter. We used multilevel Poisson and logistic regression to examine associations between workload and length of stay (LOS), return to the Emergency Department (ED), and readmission. We adjusted for sociodemographic factors, patient complexity and severity of illness, and weekend admission (for LOS) or discharge (for ED visits or readmission). RESULTS: We analyzed 38,141 hospitalizations. Median patient age was 64 years (IQR 51-78 years), 53% were female, and 34% were nonwhite. Mean workload was 15 patients (SD 3 patients; range 10-34 patients). LOS was prolonged by 0.05 days (95% CI 0.02, 0.08; p(0.001) when comparing the 75th workload percentile (16 patients) to the 25th workload percentile (13 patients). There were no associations between workload and ED visits or readmission within 7 and 30 days. CONCLUSIONS: There was a statistically significant but modest relationship between workload and LOS; workload was not associated with ED visits or readmissions.Given clinical reports of the deleterious effects of increased hospitalist workload, there is a need for prospective research assessing a range of outcomes, beyond those measurable in contemporary EHR data.