Association of Sociodemographic Characteristics With US Medical Student Attrition

Accelerated competency-based education in primary care (ACE-PC): a 3-year UC Davis and Kaiser permanente partnership to meet California's primary care physician workforce needs

PROBLEM

Our nation faces an urgent need for more primary care (PC) physicians, yet interest in PC careers is dwindling. Students from underrepresented in medicine (UIM) backgrounds are more likely to choose PC and practice in underserved areas yet their representation has declined. Accelerated PC programs have the potential to address workforce needs, lower educational debt, and diversify the physician workforce to advance health equity.

APPROACH

With support from Kaiser Permanente Northern California (KPNC) and the American Medical Association's Accelerating Change in Medical Education initiative, University of California School of Medicine (UC Davis) implemented the Accelerated Competency-based Education in Primary Care (ACE-PC) program - a six-year pathway from medical school to residency for students committed to health equity and careers in family medicine or PC-internal medicine. ACE-PC accepts 6-10 students per year using the same holistic admissions process as the 4-year MD program with an additional panel interview that includes affiliated residency program faculty from UC Davis and KPNC. The undergraduate curriculum features: PC continuity clinic with a single preceptor throughout medical school; a 9-month longitudinal integrated clerkship; supportive PC faculty and culture; markedly reduced student debt with full-tuition scholarships; weekly PC didactics; and clinical rotations in affiliated residency programs with the opportunity to match into specific ACE-PC residency tracks.

OUTCOMES

Since 2014, 70 students have matriculated to ACE-PC, 71% from UIM groups, 64% are first-generation college students. Of the graduates, 48% have entered residency in family medicine and 52% in PC-internal medicine. In 2020, the first graduates entered the PC workforce; all are practicing in California, including 66% at federally qualified health centers, key providers of underserved care.

Workforce Diversity and Equity Among Critical Care Physicians

Health disparities persist among minoritized populations. A diverse clinician workforce may help address these disparities and improve patient outcomes; however, diversity in the critical are workforce (particularly among women and those historically underrepresented in medicine (URiM)) is lacking. This review describes factors contributing to low respresentation of women and URiM in critical care medicine, and proposes strategies to overcome those barriers.

Individual values, the social determinants of health, and flourishing among medical, physician assistant, and nurse practitioner students

The purpose of this study is to explore how demographics and individual values, qualities, and personality traits are associated with perceptions of flourishing among medical (MD), physician assistant (PA), and nurse practitioner (NP) students. Current MD, PA, and NP students from two academic medical centers were recruited to participate in this cross-sectional study between August 6 and October 9, 2023. Participants completed the Secure Flourish Index (traditional SFI) and then applied a percentage weight to each of the six flourishing domains based on perceived relative importance to their overall flourishing. Additional survey questions included demographics and multiple validated instruments: WellRx, 2 Question Maslach Burnout Inventory, Brief COPE Inventory, the Short Grit Scale, and Duke University Religion Index. Descriptive statistics, ANOVA, correlation, and regression analyses were performed with an alpha of 0.05. A total of 393 of 1820 eligible students began the survey (21.6%) while 280, (15.4%) were included in the analysis. Traditional SFI scores were higher with higher grit (r = .368, p < .001). Traditional SFI scores were lower with higher WellRx (r = -.336, p < .001), burnout (r = -.466, p < .001), or avoidant (r = -.453, p < .001) coping style. Scores were about 10 points lower for students who had considered leaving training in the past 6 months (M = 75.3, SD = 16.2) than those who had not (M = 85.6, SD = 14.4; p < .001). The SFI domain of physical and mental health had the highest relative percentage weight (20.2% (SD 8.4)) but was second to lowest in mean domain flourishing score (mean 6.5, SD 1.7). While participants placed high value on physical and mental health, they reported relatively low flourishing in this area. Targeted interventions to improve the ability for students to cope with the hardships of training and life, as well as supports structured to address the social and structural determinants of health may improve flourishing among students with similar values.

Changing the Approach in Supporting and Advancing Underrepresented in Medicine (UIM) Medical Students

Introduction

Research has shown the importance of diversity in improving patient care. Medical students from backgrounds underrepresented in medicine (UIM) face unique challenges, including minority tax, stereotype threat, and expectations to be the sole representative of their identity group. Mentors must be aware of these challenges and develop skills to address them.

Methods

We designed a 90-minute workshop about the challenges UIM students encounter in medical school and best practices in mentorship. Target audience and facilitators were undergraduate medical educators. Three videos and questions for case-based facilitated small-group discussion with medical school faculty and administrators were included. Using a retrospective pre-post design, we elicited participants' confidence level in recognizing and addressing issues UIM students may experience and plans to apply skills gained in the workshop.

Results

Workshop participants (N = 57) reported a mean increase in confidence rating of 20-26 points out of 100 for recognizing, identifying, and applying skills related to optimal UIM mentorship (mean confidence: 53-60 preworkshop, 79-81 postworkshop). Participants also reported a mean of 82 in readiness to apply skills learned. Participants rated the workshop a 4.6 in overall helpfulness on a 5-point Likert scale (1 = not helpful, 5 = extremely helpful).

Discussion

Health care professionals working with UIM medical students have an essential role in mentorship and support. This workshop provides a structured forum to discuss challenges and build awareness, comfort, and skills regarding engaging in meaningful discussions about race and the experiences of medical students, even when identities are incongruent.

Exploring the impact of depression, anxiety, stress, academic engagement, and dropout intention on medical students' academic performance: A prospective study

BACKGROUND

Depression, anxiety, and stress (DAS) have been linked to poor academic outcomes. This study explores the relationships among DAS, academic engagement, dropout intentions, and academic performance - measured by Grade Point Average (GPA) - in medical students. It aims to understand how these factors relate to each other and predict academic performance.

METHODS

Data were collected from 351 medical students (74.9 % female) through an online survey. The average age was 20.2 years. Psychometric instruments measured DAS, academic engagement, and dropout intentions. Structural equation modeling was used to test the relationships between these variables and their prediction of GPA.

RESULTS

DAS was negatively associated with academic engagement β̂=-0.501p<0.001 and positively associated with dropout intentions β̂=0.340p<0.001. Academic engagement positively predicted GPA β̂=0.298p<0.001 and negatively associated with dropout intentions β̂=-0.367p<0.001. DAS had a nonsignificant direct effect on GPA β̂=-0.008p=0.912. However, the indirect effect of DAS - via academic engagement - on GPA and dropout intention was statistically significant.

LIMITATIONS

The study's limitations include the use of a convenience sample and the collection of all variables, except GPA, at the same time point, which may affect the generalizability of the results.

CONCLUSIONS

The study supports the important role of DAS in its association with academic engagement and dropout intentions, which can predict GPA. Addressing DAS could enhance academic engagement and reduce dropout rates, leading to better academic performance.

A Guiding Model for Undergraduate Medical Education Well-Being Programs

ABSTRACT

Most medical schools have instituted undergraduate medical education (UME) well-being programs in recent years in response to high rates of medical student distress, but there is currently significant variability in the structure of UME well-being programs and limited guidance on how to best structure such programs to achieve success. In this article, the authors, all leaders of medical student well-being programs at their home institutions and members of the Association of American Medical Colleges Group on Student Affairs Committee on Student Affairs Working Group on Medical Student Well-Being between 2019 and 2023 offer guidance to the national community on how best to structure a UME well-being program. They use the current literature and their professional experiences leading well-being efforts at 7 different institutions to review the case for addressing medical student well-being, propose a guiding model, and make recommendations for strategies to implement this model.The proposed guiding model emphasizes the importance of the learning environment and efficiency of learning to medical student well-being, as well as personal resilience. Based on this model, the authors recommend specific and tangible well-being strategies to implement systemic interventions to improve the learning environment, efficiency of learning, and personal resilience, including formalizing the well-being program; hiring qualified, dedicated, and empowered well-being leadership with clear responsibilities; acting as a central hub for resources and as a liaison with mental health care; and establishing robust program evaluation methods.

What Works? Fostering Inclusivity in Physician Assistant/Associate Education: The Retention, Outreach, Alignment, and Diversity (ROAD) Framework

INTRODUCTION

There are well-known strategies to increase diversity in health professions education, evidence is sparse on how such strategies are practically implemented and longitudinally sustained. This study investigated the most widely used strategies across physician assistant/associate (PA) educational programs that have consistently demonstrated the ability to graduate racial and ethnic underrepresented students.

METHODS

Following a grounded theory, qualitative interviews were conducted with 41 nationally accredited PA programs identified as top performers in consistently graduating racial and ethnic underrepresented students. Semistructured interviews were conducted with a program representative focused on ascertaining the characteristics and strategies attributable to the successful recruitment and retention of underrepresented PA matriculants. The interviews comprehensively explored program resources, efforts, and practices. Transcripts were coded, and themes were identified.

RESULTS

The study revealed 4 overarching themes: (1) Pathways from the Community to the Program and Into Healthcare; (2) Dedication to Student Retention and Support; (3) Commitment to Diverse and Inclusive Learning Environments; and (4) Alignment of Mission, Inclusive Action, and Improving Diversity Outcomes. Based on these emerging themes, we propose a new diversity framework that hinges on Retention, Outreach, Alignment, and Diversity (ROAD Framework). This framework seeks to explain the overarching goals, high-impact behaviors, and actionable steps that can be effectively implemented across PA education to facilitate further diversification.

DISCUSSION

This study illuminated on What Works to foster diversity in PA programs. By embracing and implementing the ROAD Framework, institutions can effectively address the persistent issue of underrepresentation and contribute to cultivating a more inclusive and representative healthcare workforce.

An exploration of values in medical school admissions processes: the interplay between contextual factors, admissions practices, and validity

Medical school admissions is a contentious and high stakes selection activity. Many assessment approaches are available to support selection; but how are decisions about building, monitoring, and adapting admissions systems made? What shapes the processes and practices that underpin selection decisions? We explore how these decisions are made across several Canadian medical schools, and how values shape the creation, monitoring, and adaptation of admissions systems. Using phenomenography (a qualitative method suited to examining variability), the authors analyzed interviews with 10 current or previous heads of admissions from 10 different undergraduate medical education programs in Canada. Interviews were conducted in English and French, and data was collected between 2016 and 2017 (therefore participants no longer hold these roles). Data was coded and analyzed iteratively, focusing on identifying underlying values, and exploring how these values shape admissions practices and considerations for validity. Eight different intersecting values were identified. Of these, four were shared across all participants: critically questioning the process and tools, aiming for equity, striving for better, and embracing the challenges of change. The expression of these values depended on different contextual variables (e.g., geographic location, access to expertise, resource availability), and values shaped how admissions systems were built, enacted, and monitored for quality. Ultimately, values shaped: (1) admissions practices resulting in different candidates being offered admission, and (2) how arguments supporting score interpretation are built (i.e., validity). This study documents various values that influence admissions processes, practices, and quality monitoring. The values that shape what is assessed, how it is assessed, and how fair and defensible practices are conceptualized have significant impact, ultimately determining who is selected. These values-whether implicit or explicit-result in intended and unintended consequences in selection processes. However, these values are rarely explicitly examined and questioned, leaving it uncertain as to which consequences are the intended outcomes of deliberately chosen values, and which are unintended consequences of implicitly held values of admissions systems and their actors.

An Interactive Allyship and Privilege Workshop for Trainees in Medicine

Introduction

Despite growing efforts to increase diversity in recruitment and to teach principles of diversity, equity, and inclusion (DEI), representation of individuals underrepresented in medicine continues to fall short. This demonstrates a need for efforts that target the work environment and culture to increase retention alongside existing recruitment initiatives. We designed this interactive allyship workshop with a focus on building skills necessary for being an ally that has been missing in existing allyship curricula.

Methods

This workshop was led by multidepartmental faculty with experience in DEI training. Participants engaged in a number of interactive activities to reflect on their own identities and privilege and practiced ways to engage in difficult conversations. Prior to the workshop, participants completed a survey that was repeated at the workshop's completion to evaluate their perspective change and understanding of allyship. We also collected responses to a self-reflective exercise during the workshop.

Results

Participants included 68 anesthesia and surgery attendees, 53 of whom (78%) completed the postsurvey. Participants strongly agreed that this workshop was important to the workplace and medical training. Themes from the self-reflective exercises included endorsement of sponsorship and mentorship activities, community support, and advocacy.

Discussion

Interactive skill-building activities are important and effective at helping trainees develop as allies. Long-term follow-up is needed to assess longitudinal knowledge retention and translation into behavioral change to create a more inclusive and supportive work environment.

Resident Recruitment in a New Era

ABSTRACT

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Prevalence and Predictors of Burnout Among Resident Family Physicians

BACKGROUND AND OBJECTIVES

Resident burnout may affect career choices and empathy. We examined predictors of burnout among family medicine residents.

METHODS

We used data from the 2019-2021 American Board of Family Medicine Initial Certification Questionnaire, which is required of graduating residents. Burnout was a binary variable defined as reporting callousness or emotional exhaustion once a week or more. We evaluated associations using bivariate and multilevel multivariable regression analyses.

RESULTS

Among 11,570 residents, 36.4% (n=4,211) reported burnout. This prevalence did not significantly vary from 2019 to 2021 and was not significantly attributable to the residency program (ICC=0.07). Residents identifying as female reported higher rates of burnout (39.0% vs 33.4%, AOR=1.29 [95% CI 1.19-1.40]). Residents reporting Asian race (30.5%, AOR=0.78 [95% CI 0.70-0.86]) and Black race (32.3%, AOR=0.71 [95% CI 0.60-0.86]) reported lower odds of burnout than residents reporting White race (39.2%). We observed lower rates among international medical graduates (26.7% vs 40.3%, AOR=0.54 [95% CI 0.48-0.60]), those planning to provide outpatient continuity care (36.0% vs 38.7%, AOR=0.77 [95% CI 0.68-0.86]), and those at smaller programs (31.7% for <6 residents per class vs 36.3% for 6-10 per class vs 40.2% for >10 per class). Educational debt greater than $250,000 was associated with higher odds of burnout than no debt (AOR=1.29 [95% CI 1.15-1.45]).

CONCLUSIONS

More than one-third of recent family medicine residents reported burnout. Odds of burnout varied significantly with resident and program characteristics.

Ethical guidelines for antiracism work in medicine: lessons from the antiracist healing collaborative

An explosion of antiracism in medicine efforts have transpired since 2020. However, no ethical guidelines exist to guide them. This oversight is concerning because the racism and white supremacy rife within medicine can easily thwart them. This article addresses this gap by highlighting ethical guidelines for antiracism work in medicine. We present nine core tenets derived from our experience forming the Antiracist Healing Collaborative (AHC), a medical student-led initiative committed to developing bold and disruptive antiracist medical education content. Our lessons developing and implementing these tenets can guide other antiracism in medicine collaborations striving to promote liberation and healing, rather than recapitulating the racism and white supremacy culture embedded within medicine. We close by reflecting on how these tenets have steadied our recent decision to draw AHC to a close. They have allowed us to honour what we achieved together, strengthen the relationship that formed the foundation for our activism and bolster the shared antiracism mission that will guide our individual journeys moving forwards. The first of their kind, our ethical guidelines for antiracism work in medicine can facilitate greater recognition of the risks embedded in anti-oppression work transpiring in academic settings.

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.

Diversity of PA cohorts during the evolution to an entry-level master's degree

OBJECTIVE

This study evaluated the racial and ethnic diversity of physician associate/assistant (PA) graduating cohorts during the profession's transition from a standard undergraduate degree to an entry-level master's degree.

METHODS

Using all existing program reports from the Physician Assistant Education Association (1985-2019), we explored potential associations between changes in tuition, degree types offered, and racial/ethnic makeup of graduating cohorts.

RESULTS

We observed a strong negative association between Black students and graduates versus increasing tuition and the rise of master's level programs.

CONCLUSIONS

More equitable opportunities for joining the PA profession may be needed.

Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce

Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.

Latinas in medicine: evaluating and understanding the experience of Latinas in medical education: a cross sectional survey

BACKGROUND

The percentage of physicians identifying as Latina has not improved despite improvements in recruitment of Latina medical students, suggesting barriers to retention and career advancement. Discriminatory experiences and mental health inflictions throughout training may contribute to difficulties in recruitment, retainment, and advancement of Hispanic/Latinx trainees, a notably understudied population.

METHODS

An anonymous, online survey was distributed to Latinas in the continental U.S. between June 22 to August 12, 2022. Eligibility criteria included: self-identifying as Hispanic/Latina, female/woman, and completing or have completed medical school, residency, or fellowship in the continental U.S. in the past 10 years. Recruitment was done via the Twitter account @LatinasInMed and outreach to Latino Medical Student Association chapters. Descriptive statistics summarized the self-reported experiences.

RESULTS

The survey included 230 Hispanic/Latinx women, mostly medical students (46.9%). A majority (54.5%) reported negative ethnicity-based interactions from patients and/or patients' families; 71.8%, from others in the medical field. High rates of depression (76.2%) and anxiety (92.6%) during training were reported by Latinas, especially medical students. Feelings of imposter syndrome and burnout were high at 90.7% and 87.4%, respectively.

CONCLUSIONS

This is the first study evaluating the unique experiences of Latinas in medicine, who reported discrimination and mental health struggles, specifically during medical school, at alarmingly high rates. Our findings could aid in creating the needed interventions to support Latinas in medical training to reduce the existing exodus of Latinas from medicine.

Medical Student Burnout by Race, Ethnicity, and Multiple Disability Status

This cohort study examines the prevalence of burnout among students underrepresented in medicine by race and ethnicity with multiple disability types.

Parent Perceptions of Trainees in Pediatric Care: Cross-Sectional Study

BACKGROUND

Clinical experience and progressive autonomy are essential components of medical education and must be balanced with patient comfort. While previous studies have suggested that most patients accept trainee involvement in their care, few studies have focused specifically on the views of parents of pediatric patients or examined groups who may not report acceptance.

OBJECTIVE

This study aims to understand parental profiles of resident and medical student involvement in pediatric care and to use latent class analysis (LCA) methodology to identify classes of responses associated with parent demographic characteristics.

METHODS

We used data from a national cross-sectional web-based survey of 3000 parents. The survey used a 5-point Likert scale to assess 8 measures of parent perceptions of residents and medical students. We included participants who indicated prior experience with residents or medical students. We compared responses about resident involvement in pediatric care with responses about student involvement, used LCA to identify latent classes of parent responses, and compared demographic features between the latent classes.

RESULTS

Of the 3000 parents who completed the survey, 1543 met the inclusion criteria for our study. Participants reported higher mean scores for residents than for medical students for perceived quality of care, comfort with autonomously performing an examination, and comfort with autonomously giving medical advice. LCA identified 3 latent classes of parent responses: Trainee-Hesitant, Trainee-Neutral, and Trainee-Supportive. Compared with the Trainee-Supportive and Trainee-Neutral classes, the Trainee-Hesitant class had significantly more members reporting age <30 years, household income < US $50,000, no college degree, and lesser desire to receive future care at a teaching hospital (all P<.05).

CONCLUSIONS

Parents may prefer greater clinical autonomy for residents than medical students. Importantly, views associated with the Trainee-Hesitant class may be held disproportionately by members of historically and currently socially marginalized demographic groups. Future studies should investigate underlying reasons for trainee hesitancy in these groups, including the possibility of mistrust in medicine.

See, seek, support: a policy framework to uplift first-generation low-income medical professionals

The First-Generation and/or Low-Income (FGLI) identity is not readily visible, encapsulating those who are the first in their families to complete a 4-year college degree and/or those living near or below the poverty line. In the backdrop of unprecedented levels of socioeconomic inequality in a country where household income predicts educational attainment, we explore the current state of U.S. society regarding socioeconomic status and health care. We describe challenges in diversifying the health care workforce and present a multi-pronged policy approach for visibilizing, recruiting, supporting, and retaining FGLI trainees in medicine, with the promise of improving the quality of health care delivery altogether. Through this work, we aim to render the field of medicine more equitable for trainees, physicians, and patients alike.

Twelve tips for providing academic remediation to widening access learners in medical education

As medical schools expand access and diversity through widening access initiatives, there is an increasing need to provide academic remediation for learners during their first year in medical school. The previous educational experiences of widening access learners are often mismatched for continuing success in medical school. This article offers 12 tips for providing academic remediation to widening access learners and draws on insights from the learning sciences and research in psychosocial education to support academic development within a holistic framework.

The Long Shadow: A Historical Perspective on Racism in Medical Education

To dismantle racism in U.S. medical education, people must understand how the history of Christian Europe, Enlightenment-era racial science, colonization, slavery, and racism shaped modern American medicine. Beginning with the coalescence of Christian European identity and empire, the authors trace European racial reasoning through the racial science of the Enlightenment into the White supremacist and anti-Black ideology behind Europe's global system of racialized colonization and enslavement. The authors then follow this racist ideology as it becomes an organizing principle of Euro-American medicine and examine how it manifests in medical education in the United States today. Within this historical context, the authors expose the histories of violence underlying contemporary terms such as implicit bias and microaggressions. Through this history, they also gain a deeper appreciation of why racism is so prevalent in medical education and how it affects admissions, assessments, faculty and trainee diversity, retention, racial climate, and the physical environment. The authors then recommend 6 historically informed steps for confronting racism in medical education: (1) incorporate the history of racism into medical education and unmask institutional histories of racism, (2) create centralized reporting mechanisms and implement systematic reviews of bias in educational and clinical activities, (3) adopt mastery-based assessment in medical education, (4) embrace holistic review and expand its possibilities in admissions, (5) increase faculty diversity by using holistic review principles in hiring and promotions, and (6) leverage accreditation to combat bias in medical education. These strategies will help academic medicine begin to acknowledge the harms propagated throughout the history of racism in medicine and start taking meaningful steps to address them. Although the authors have focused on racism in this paper, they recognize there are many forms of bias that impact medical education and intersect with racism, each with its particular history, that deserve their own telling and redress.

"Comprehensive Healthcare for America": Using the Insights of Behavioral Economics to Transform the U. S. Healthcare System

"Comprehensive Healthcare for America" is a largely single-payer reform proposal that, by applying the insights of behavioral economics, may be able to rally patients and clinicians sufficiently to overcome the opposition of politicians and vested interests to providing all Americans with less complicated and less costly access to needed healthcare.

Understanding the factors that influence matriculation and persistence in Black medical students

Purpose

The Association of American Medical Colleges' (AAMC) Strategic Plan lists 10 action plans one of which is focused on understanding how systemic barriers, such as racism and access to quality education, may negatively impact diversity in academic medicine. Thus, the purpose of this study was to understand the factors that impact the matriculation and persistence of Black medical students.

Method

A qualitative phenomenological study using Tinto's Model of Institutional Departure as an organizing framework was used for this study. Participants were asked a series of questions covering topics related to their goals, their medical school experience, their preparation for medical school, what could improve their medical school experience, and advice for future Black medical students.

Results

Forty in-depth semi-structured interviews were conducted during the fall 2022 term from October to December with Black medical students enrolled in over 16 US or Caribbean medical schools. Findings reported that two factors impacted matriculation for Black medical students (exposure to the medical field and resources, particularly financial resources). Findings also reported that three factors impacted the persistence of Black students once in medical school (diversity, support, and emotional resources).

Conclusion

The five factors identified by participants that impact matriculation and persistence for Black medical students can be used by medical schools to increase their enrollment and graduation of Black students.

The 2022 Joseph W. St Geme, Jr, Leadership Award Address-Diversity and Social Justice: The Field of Pediatrics Can and Should Lead

The following is an address given by the 2022 recipient of the Joseph W. St. Geme, Jr. Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies meeting on April 22, 2022.

Tailored Mentorship for the Underrepresented and Allies in Radiation Oncology: The Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee Mentorship Experience

PURPOSE

There are limited opportunities for mentorship for underrepresented in medicine (URM) trainees and physicians in radiation oncology (RO). The purpose of this study was to create and evaluate a formal mentorship program open to URMs and allies with interests in diversity, equity, and inclusion.

METHODS AND MATERIALS

A mentorship program incorporating a virtual platform was designed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee. It was structured to include 6 sessions over 6 months with matched mentor-mentee pairs based on responses to a publicized online interest form. A compilation of evidence-based guidelines was provided to optimize the mentorship relationship. Linked pre- and postprogram surveys were administered to collect demographic data, define baseline goals and level of support, and evaluate program satisfaction.

RESULTS

Thirty-five mentor-mentee pairs were matched; 31 mentees completed the preprogram survey and 17 completed the postprogram survey. Preprogram, only 3 mentees (9.7%) reported satisfaction with current mentorship and 5 (16%) reported mechanisms or mentorship in place at their program to support URMs. On the postprogram survey, mentees reported high satisfaction with areas of mentorship, mentor attributes, and the program overall. Opportunities for improvement include implementation of mechanisms to enhance communication with mentor-mentee pairs and maintain longitudinal engagement.

CONCLUSIONS

In the first tailored mentorship program in RO for URMs and those with diversity, equity, and inclusion interests, our results demonstrate that there is self-reported interest for better mentorship for URMs in RO, and that a nationwide structured mentorship program can address participants' goals with high satisfaction. Program expansion could provide URMs and allies in RO more opportunities for career development and promote a greater sense of community and inclusion within the field.

A National Cancer Disparities Analysis of Predictors for Radiation Therapy Refusal by Race

PURPOSE

Radiation therapy (RT) refusal by patients with cancer is infrequent but is significant because it portends poor outcomes. No prior study has evaluated all five federally defined racial categories with respects to RT refusal. Here we use a large nationally representative population with cancer to determine: 1) which race of patients refuse RT the most and 2) predictive factors for RT refusal by race.

MATERIALS/METHODS

A retrospective study included patients ≥18 years old with diagnostically confirmed cancer between 2004-2017, using the National Cancer Database. All patients included were offered RT for first course treatment. Multivariable logistic regression assessed RT refusal (adjusted odds ratio [aOR]) with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, rurality, income, education, and comorbidities) and cancer characteristics (stage, cancer type, facility type, year of diagnosis, and region). Median overall survival was calculated using the Kaplan-Meier method.

RESULTS

Of 11,609,044 patients, 2,759,753 patients were included and recommended for RT by the treating physician. Median follow-up was 50 months. RT was refused by 139,383 patients (5.0%), varying by race: 416 NHPI (7.2%), 489 AIAN (5.8%), 118,186 Non-Hispanic White (5.0%), 17,427 Black (4.8%), and 2,865 Asian (4.8%) patients. The rates of annual RT refusal were increasing, especially among NHPI patients. The populations with the highest likelihood of refusing RT were NHPI (aOR=1.53, 95%CI=1.36-1.71), AIAN (aOR=1.24, 95%CI=1.12-1.37), and Black (aOR=1.11, 95%CI=1.09-1.14) patients, compared to Non-Hispanic White patients. Older age and higher comorbidity burden predicted RT refusal across all races. Median overall survival was 81 months and 144 months for patients who refused RT and received RT, respectively.

CONCLUSIONS

Indigenous and Black patients are more likely to refuse RT, which may contribute to inferior cancer outcomes. Understanding NHPI and AIAN patient perspectives and perceptions may elucidate interventions to mitigate these disparities.

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.

Engaging the Entire Learner: Pathway Program Administrators' Experiences of Providing Students with Research Experiences in Academic Medicine

Objective

Pathway programs designed to recruit and retain students from groups historically excluded from science and medicine have focused on providing academic and social support through programs that provide mentored experiences. However, for students in science, technology, engineering, math, and medicine (STEMM) majors, students from underrepresented groups tend to leave science-oriented programs at higher rates than students who are not underrepresented. As such, they are also underrepresented in medical fields, including academic medicine. Insight into how pathway programs contribute to addressing this issue is critical.

Methods

This study took a qualitative approach to investigating the experiences of pathway program administrators in academic medicine. Interviews were conducted with 12 program administrators working on 8 different programs throughout the country. Interviews were analyzed using directed content analysis while also allowing for the development of new themes based on the data.

Results

The codes were organized into 6 overarching themes: mentorship, student engagement, determining program success, administrative time and program logistics, diversity and inclusion, and transition to virtual learning (due to COVID-19). Within each of these themes, program administrators described challenges along with some strategies programs employed to overcome these challenges.

Conclusions

The greatest overall challenge described was finding and sustaining relationships with faculty and nonfaculty mentors. To address this issue, many programs have worked within their institutions to incentivize this work. For student engagement, program administrators reported issues with tailoring to skill sets and interests of multiple students while still fostering community. Program administrators have also expanded definitions for determining program success. Program administration is a challenge, and more support staff or time to devote to these programs is often needed. Diversity challenges encompass recruiting faculty and students from groups underrepresented in STEMM and the logistics of getting all necessary accommodations for students. Finally, transition to virtual learning, due to the COVID-19 pandemic, brought about challenges and opportunities.

Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014-19

The US physician workforce does not reflect the racial and ethnic makeup of the country's population, despite efforts to promote diversity. Becoming a physician requires significant time and financial investment, and populations that are underrepresented in medicine have also been excluded from building wealth. Understanding the differential burden of debt by race and ethnicity may inform strategies to improve workforce diversity. We used 2014-19 data on postgraduate resident trainees from the Association of American Medical Colleges to examine the association between race and ethnicity and debt independent of other demographics and residency characteristics. Black trainees were significantly more likely to have every type of debt than the overall sample and all other racial and ethnic groups (96 percent of Black trainees had any debt versus 83 percent overall; 60 percent had premedical education loans versus 35 percent overall, and 50 percent had consumer debt versus 25 percent overall). American Indian/Alaska Native, Hispanic, and Native Hawaiian/Pacific Islander trainees were more likely to have debt compared with White and Asian trainees. Overall, debt prevalence decreased over time and varied by specialty; however, for Black trainees, debt decreased minimally over time and was stable across specialties. Scholarships, debt relief, and financial guidance should be explored to improve diversity and inclusion in medicine across specialties.

Compassionate Off-Ramps: The Availability of Terminal Master's Degrees in US Medical Schools

Medical students who underperform or find they are not a "good fit" for medicine have limited options. A terminal master's degree represents an exit alternative that recognizes students' completed coursework and acknowledges their commitment to the medical sciences. Although medical educators have called for the creation of such programs, termed "compassionate off-ramps," the prevalence of degree offerings in US programs is unknown. In the fall of 2020, a survey was sent to Student Affairs Deans at 141 LCME-accredited MD programs; 73 institutions responded (52%). Terminal master's degrees were offered by 19% of respondent institutions (n = 13). While 85% of those without a terminal master's (n = 48) endorsed degree benefits, only 36% (n = 21) had plans to create the degree. This study demonstrates that few US medical schools offer a terminal master's degree, leaving students who exit medicine with high levels of debt without an avenue for a degree to support employment or future academic pursuits. The authors identify implications for students, particularly those who are at a higher risk of failing Step 1, such as students who are underrepresented in medicine, socioeconomically disadvantaged, or who have a disability and are unaccommodated. Potential barriers to terminal master's program creation are identified and mitigating strategies are recommended.

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.

Rates of Medical Student Placement Into Graduate Medical Education by Sex, Race and Ethnicity, and Socioeconomic Status, 2018-2021

This cohort study investigates whether different rates of medical student placement into graduate medical education exist by sex, race and ethnicity, and socioeconomic status from 2018 to 2021.