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

Equity, diversity, and…exclusion? A national mixed methods study of "belonging" in Canadian undergraduate medical education

Equity, diversity, and inclusion remain a prominent focus in medical schools, yet the phenomenon of "belonging" has arguably been overlooked. Little is known regarding how belonging is experienced by medical students from groups that face systemic oppression and exclusion. We employed a sequential explanatory mixed methods design to explore how students from equity-deserving groups (EDGs) experience belonging during medical school, including those who are women, racialized, Indigenous, disabled, and 2SLGBTQIA+. First, we conducted a national cross-sectional survey of medical students (N = 480) measuring four constructs: belonging, imposter syndrome, burnout, and depression. Belonging scores were overall lower for students from EDGs and, more specifically, significantly lowest amongst racialized students. Structural equation models show that poor sense of belonging precedes imposter syndrome and further exacerbates burnout and depression. Next, we sampled and interviewed students (N = 16) from the EDG whose belonging scores were significantly lowest. Participants described the essence of belonging as being able to exist as one's "true self" while emphasizing feelings of acceptance, comfort, and safety as well as being valued and seen as an equal - yet described how routine experiences of "othering" inhibited a sense of belonging, often due to differences in social identity and structural privilege. Poor sense of belonging negatively affected learners' well-being and career trajectory. We illuminate the range of psychological and professional consequences associated with diminished sense of belonging and highlight the need to expand traditional notions of equity, diversity, and inclusion to consider structural barriers to belonging.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Medical students' perception of their 'distance travelled' in medical school applications

INTRODUCTION

Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey.

METHODS

The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description.

RESULTS

A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society.

DISCUSSION

Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools.

Facilitators and Barriers to the Adoption of Holistic Practices for Inclusive Recruitment in Graduate Medical Education

OBJECTIVE

A diverse physician workforce ensures equitable care. The holistic review of residency applications is one strategy to enhance physician diversity; however, little is known about current adoption and the factors that facilitate/impede the adoption of holistic recruitment practices (HRPs) by graduate medical education (GME) residency, and fellowship program directors (PDs). To describe the current state and explore, the barriers/facilitators to the adoption of HRPs at our institution.

METHODS

We disseminated information about HRP within our program between 2021 and 2022. In May 2022, a survey of 73 GME PDs assessed current recruitment practices and self-reported barriers to holistic recruitment. Holistic Recruitment Scores (HRSs) reflecting the adoption of best practices were tabulated for each program and compared to identify predictors of adoption.

RESULTS

73/80 (92%) of PDs completed the survey. Programs whose PDs had higher academic rank, total number of trainees, and female trainees in the past 3 years had higher HRSs. Program size was directly correlated with HRS. Most (93%) PDs felt their current efforts were aligned to increase diversity and 58% felt there were no barriers to the adoption of holistic review. The most reported barriers were lack of time and knowledge/expertise in diversity, equity, and inclusion (DEI), both reported by 16 out of 73 PDs (22%).

CONCLUSION

While most PDs implemented some HRP, institutional and departmental support of program directors through the commitment of resources (eg, staffing help and subject matter experts/coaches hiring) are crucial to overcome barriers.

Diversity in Mission Statements and Among Students at US Medical Schools Accredited Since 2000

Importance

Diversity in the physician workforce improves patient care and decreases health disparities. Recent calls for social justice have highlighted the importance of medical school commitment to diversity and social justice, and newly established medical schools are uniquely positioned to actively fulfill the social mission of medicine.

Objective

To identify diversity language in the mission statements of all medical schools accredited since 2000 and to determine whether the presence of diversity language was associated with increased diversity in the student body.

Design, Setting, and Participants

Cross-sectional study of public websites conducted between January 6, 2023, and March 31, 2023. Qualitative content analysis of mission statements was conducted using a deductive approach. Eligible schools were identified from the 2021-2022 Medical School Admission Requirements and American Medical Colleges and American Association of Colleges of Osteopathic Medicine websites. Each school's publicly available website was also reviewed for its mission and student body demographics. All United States allopathic and osteopathic medical schools that have been accredited and have enrolled students since 2000.

Exposure

Content analysis of medical school mission statements.

Main Outcomes and Measures

Prevalence of diversity language in medical school mission statements and its association with student body racial diversity. Data were analyzed in 5-year groupings: 2001 to 2005, 2006 to 2010, 2011 to 2015, and 2016 to 2020).

Results

Among the 60 new medical schools (33 [55%] allopathic and 27 [45%] osteopathic; 6927 total students), 33 (55%) incorporated diversity language into their mission statements. In 2022, American Indian or Alaska Native individuals accounted for 0.26% of students (n = 18), Black or African American students constituted 5% (n = 368), and Hispanic or Latinx individuals made up 12% (n = 840). The percentage of schools with diversity language in their mission statements did not change significantly in schools accredited across time frames (60% in 2001: mean [SE], 0.60 [0.24] vs 50% in 2020: mean [SE], 0.50 [0.11]). The percentage of White students decreased significantly over the time period (26% vs 15% students in 2001-2005 and 2016-2020, respectively; P < .001). No significant differences were observed in student body racial or ethnic composition between schools with mission statements that included diversity language and those without.

Conclusions and Relevance

In this cross-sectional study of US medical schools accredited since 2000, diversity language was present in approximately half of the schools' mission statements and was not associated with student body diversity. Future studies are needed to identify the barriers to increasing diversity in all medical schools.

Racial, Ethnic, and Sex Diversity Trends in Health Professions Programs From Applicants to Graduates

Importance

Diversity is an essential element of an effective health care system. A key to developing a diverse workforce is establishing a diverse student population in health professions programs.

Objective

To examine the diversity of students in Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD), and Doctor of Pharmacy (PharmD) programs with emphasis on the trends of underrepresented minoritized groups (American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander) and sex relative to the overall age-adjusted US population.

Design, Setting, and Participants

This cross-sectional study used deidentified, self-reported data from 2003 to 2019 from the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, American Dental Education Association, American Dental Association, and American Association of Colleges of Pharmacy. Data analysis was performed from 2003 to 2004 and from 2018 to 2019.

Exposures

Data on the race, ethnicity, and sex of applicants, matriculants, and degrees conferred by health professions programs were collected and compared with the age-adjusted population in the US Census (aged 20-34 years) over time.

Main Outcomes and Measures

The main outcomes were trends in the proportions of underrepresented minoritized groups and sex diversity among applicants, matriculants, and degrees conferred relative to the overall age-adjusted US population. Trends were measured using the representation quotient, which is defined as the ratio of the proportion of each subgroup to the total population of applicants, matriculants, or graduates relative to the proportion for that subgroup within the US Census population of similar age. Regression analysis was used to evaluate the trend over time.

Results

A total of 594 352 applicants were analyzed across the examined programs. From 2003 to 2019, the proportions of individuals from underrepresented groups increased for DDS and DMD (applicants, from 1003 of 8176 to 1962 of 11 298 [5.1%]; matriculants, from 510 of 4528 to 966 of 6163 [4.2%]; degrees awarded, from 484 of 4350 to 878 of 6340 [2.7%]), PharmD (applicants, from 9045 of 71 966 to 11 653 of 50 482 [9.0%]; matriculants, from 5979 of 42 627 to 10 129 to 62 504 [6.3%]; degrees awarded, from 922 of 7770 to 2190 of 14 800 [3.0%]), and DO (applicants, from 740 of 6814 to 3478 of 21 090 [5.4%]; degrees awarded, 199 of 2713 to 582 of 6703 [1.4%]) programs, but decreased for MD programs (applicants, from 6066 of 34 791 to 7889 of 52 777 [-2.3%]; matriculants, 2506 of 16 541 to 2952 of 21 622 [-2.4%]; degrees awarded, from 2167 of 15 829 to 2349 of 19 937 [-0.1%]). Compared with age-adjusted US Census data, all programs had more Asian students and fewer male, American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander students (representation quotient <1).

Conclusions and Relevance

In this cross-sectional study, most of the health professions in the study saw increases in underrepresented minority applicants, matriculants, and degrees conferred from 2003 to 2019; however, all programs were below the age-adjusted US Census data. The increased racial, ethnic, and sex diversity in the programs illustrates progress, but additional strategies are needed to achieve a more representative health care workforce.

Holistic Admissions at UC Davis-Journey Toward Equity

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

Factors and barriers that influence the matriculation of underrepresented students in medicine

Despite many initiatives over more than 4 decades, the diversity of United States physicians still does not reflect the diversity of the United States population. The present study undertakes a literature review of the last 30 years to investigate barriers and protective factors underrepresented college students encounter as applicants for medical school. Known barriers that influence matriculation into medical school were analyzed such as academic metrics and test scores. Additionally, elements that are less well studied were investigated such as factors perceived as barriers by underrepresented applicants in addition to protective factors that allow them to persist in their journey in the face of difficulties and adversity.