Upholding our PROMISE: Increased representation is not enough to foster belonging in graduate medical education.

PURPOSE: Sense of belonging supports academic achievement and encourages career endurance. The purpose of this study was to characterize what individual and institutional factors influence one's sense of belonging by describing the experiences of underrepresented in medicine (UIM) paediatric and internal medicine-paediatric residents in the United States. METHOD: The authors conducted a national survey of paediatric and internal medicine-paediatric residents. The 23-item anonymous web-based survey was distributed between October 2020 and January 2021 and included questions on socio-demographic characteristics and individual perceptions on sense of belonging, value, common mission or values at a program or institution and respect. The authors used linear mixed models and fitted regression models to examine individual factors and environmental factors that impact sense of belonging, value and respect. RESULTS: Across 29 residency programs, 938 (53%) of 1748 residents completed the survey. One hundred sixty-seven (18%) self-identified as UIM. UIM residents had a lower sense of belonging than non-UIM residents [mean (SD) 3.6 (0.87) vs. 4.0 (0.57)]. Black/AA and Hispanic/Latinx residents had the lowest sense of belonging [3.5 (0.82) and 2.8 (0.93), respectively]. UIM residents demonstrated decreased sense of belonging in programs that lacked bias training and where peers discriminated against them. Sense of belonging was increased in programs where they perceived a sense of support, respect or values alignment. Surprisingly, individual UIM resident sense of belonging was not improved by having more UIM residents in a program. CONCLUSION: UIM paediatric residents experience a decreased sense of belonging during training. Programs can support sense of belonging for UIM residents by demonstrating respect and support for them and by offering systems for bias training and reporting bias and discrimination. Recruiting a greater number of UIM trainees remains important; however, compositional diversity alone does not improve a sense of belonging for UIM residents. There is continued need for structural/institutional change, including addressing institutional culture and structural racism.

A Critical Look at Racism in the Clinical Learning Environment and the Erasure of DEI Efforts.

ABSTRACT: Academic medicine has long acknowledged the importance of diversity, equity, and inclusion in the pursuit of health equity. Despite this recognition, the clinical learning environment (CLE) has struggled to foster an equitable and inclusive ecosystem that supports diverse learners and faculty.Efforts to dismantle racism in medicine represent an important approach to supporting diverse learners and faculty in the CLE, but they have fallen short of their intended impact. The reasons for this failure are complex and may include a limited understanding of the impact of racism and a misguided conviction that knowledge of harm suffered by minoritized groups is a sufficient driver of change.To advance understanding and increase motivation to dismantle racist systems within academic medicine, this paper posits 2 frameworks, Interest Convergence (IC) and Critical Whiteness Study (CWS). IC asserts that racial equity progresses only when it aligns with the interests of the majority, while CWS examines how Whiteness as a social construct upholds power and privilege, often to the detriment of White individuals themselves.Utilizing these frameworks, the authors detail how Whiteness negatively impacts the health of White people and impedes entry to medical school for low- and middle- income, first-generation White students. The authors illustrate how practices-such as patient- and family-centered care and competency-based medical education-which are intended to improve care and medical education for all, are fully aligned with and integral to diversity, equity and inclusion (DEI) principles. The authors conclude that racism and upholding Whiteness causes harm to majority as well as minoritized peoples while DEI principles provide the foundation for best practices in the CLE and improve outcomes for all.

Valuable Papers: A Year in (Re)View From the Association of Pediatric Program Directors.

Academic Pediatrics has been the official journal of the Association of Pediatric Program Directors (APPD) since 2009. The View from the APPD section of the journal is an important destination to highlight APPD members' scholarship regarding issues impacting residency and fellowship training. Since 2020, the annual commentary (Re)View from the APPD summarizes articles published in View over the past year, including their alignment with the overall APPD mission, values, and organizational priorities. This year's (Re)View summarizes the articles published over the past year, with commentary on how the scholarship aligns with APPD values.

The Office of Belonging, Equity, Diversity, and Inclusion in The Warren Alpert Medical School: Aligning Goals, Programming, and Outcomes for Health Equity.

Although United States (US) medical institutions discuss the importance of diversity, equity, and inclusion, there is little guidance about the process by which these concepts can be attained programmatically within institutions. The Office of Belonging, Equity, Diversity, and Inclusion (OBEDI) at The Warren Alpert Medical School of Brown University intends to rise to the challenge and share knowledge and experience with other institutions. Program design models, and the alignment of inputs, outputs, and outcomes for the short-term and long-term are illustrated. OBEDI's unique model of how each of these concepts contribute towards health equity, from the individual to the community, is also explained. Finally, OBEDI shares promising practices and future directions.

Upholding Our PROMISE: Underrepresented in Medicine Pediatric Residents' Perspectives on Interventions to Promote Belonging.

PURPOSE: Underrepresented in medicine (UIM) residents experience challenges during training that threaten their sense of belonging in medicine; therefore, residency programs should intentionally implement interventions to promote belonging. This study explored UIM pediatric residents' perspectives on current residency program measures designed to achieve this goal. METHOD: The authors conducted a secondary qualitative analysis as part of a national cross-sectional study, PROmoting Med-ed Insight into Supportive Environments (PROMISE), which explored pediatric residents' experiences and perspectives during training in relation to their self-identities. A 23-item web-based survey was distributed through the Association of Pediatric Program Directors Longitudinal Educational Research Assessment Network from October 2020 to January 2021. Participants provided free-text responses to the question "What are current measures that promote a sense of belonging for the UIM community in your training program?" The authors used conventional content analysis to code and identify themes in responses from UIM participants. RESULTS: Of the 1,748 residents invited to participate, 931 (53%) residents from 29 programs completed the survey, with 167 (18%) identifying as UIM. Of the 167 UIM residents, 74 (44%) residents from 22 programs responded to the free-text question. The authors coded more than 140 unique free-text responses and identified 7 major themes: (1) critical mass of UIM residents; (2) focused recruitment of UIM residents; (3) social support, including opportunities to build community among UIM residents; (4) mentorship; (5) caring and responsive leadership; (6) education on health disparities, diversity, equity, inclusion, and antiracism; and (7) opportunities to serve, including giving back to the local community and near-peer mentorship of UIM premedical and medical students. CONCLUSIONS: This is the first national study to describe UIM pediatric residents' perspectives on interventions that promote a sense of belonging. Programs should consider implementing these interventions to foster inclusion and belonging among UIM trainees.

Three Years of X + Y Scheduling: Longitudinal Assessment of Resident and Faculty Perceptions.

OBJECTIVE: Five pediatric residency programs implemented true X + Y scheduling in 2018 where residents have continuity clinic in "blocks" rather than half-day per week experiences. We report the impact X + Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences over a 3-year timeframe. METHODS: Electronic surveys were sent to residents and faculty of the participating programs prior to implementing X + Y scheduling and annually thereafter (2018-2021). Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotations. Data were analyzed using z-tests for proportion differences. RESULTS: One hundred and eight six residents were sent the survey preimplementation and 254 to 289 postimplementation with response rates ranging from 47% to 69%. Three hundred and seventy-eight to 395 faculty members were sent the survey with response rates ranging from 26% to 51%. Statistically significant (P < .05) sustained perceived improvements over 3 years with X+Y were seen in outpatient continuity, inpatient workflow, and time for teaching both inpatient and in continuity clinic. CONCLUSIONS: X + Y scheduling can lead to perceived improvements in various aspects of pediatric residency programs. Our study demonstrates these improvements have been sustained over 3 years in the participating programs.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities.

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Opportunities for Mitigating Bias in the Process and Priorities for Pediatric Chief Resident Selection.

OBJECTIVE: To describe the current processes and priorities for pediatric chief resident (CR) selection, to characterize pediatric CR demographics in the past 5 years nationally, and to identify opportunities for addressing bias in the process of pediatric CR selection. METHODS: We used a cross-sectional study design with an anonymous national survey of pediatric program directors (PDs) through a web-based platform in January 2020. RESULTS: A total of 92 of 200 (46%) of PDs responded. About 16% of CR are underrepresented in medicine (UIM) by race/ethnicity. The influential factors most commonly cited in selection were nominations from faculty (84%) and peers (77%), followed by fit with other co-chiefs (68%). Only 17% reported having a specific method to mitigate bias in CR selection, most commonly involving multiple stakeholders in the process. CONCLUSIONS: Current CR selection relies on processes with the potential to introduce bias. Programs have opportunities to address bias in the CR selection process by reevaluating methods vulnerable to bias, including peer/faculty nominations, fit with peers, ITE scores, and assessments through the use of more objective selection tools.

The Impact of the COVID-19 Pandemic on Pediatric Graduate Medical Education: Lessons Learned and Pathways Forward.

In this article, the authors describe the impact of the COVID-19 pandemic on pediatric graduate medical education (GME), including the impact on clinical experiences for trainees, teaching methods used, trainee wellness, GME leader wellness and support, and the traditional interview process. A thorough literature review was done to identify impacts of the COVID-19 pandemic on pediatric GME. In addition, information was collected through Association of Pediatric Program Directors virtual cafes and conferences. Positive changes for GME from the COVID-19 pandemic included: the rapid transition to telehealth; asynchronous learning allowing for increased cross-program collaboration; innovative online teaching modalities; increased flexibility and decreased cost of online recruitment; and shared innovations across pediatric GME. Challenging aspects of the COVID-19 pandemic included: decreased learning about common childhood illnesses, such as bronchiolitis, acute otitis media, and influenza; decreased patient volumes and patient complexity in clinics and inpatient wards, leading to less practice developing efficiency, time management, and triaging skills; and an increased burden on trainees, including moral distress and decreased support from one another and other social supports. The COVID-19 pandemic has highlighted important opportunities in U.S. educational systems. As medical educators move forward, it will be important to learn from these while mitigating the negative impacts.