Improving pathways to eliminate underrepresentation in the pediatric surgery workforce: A call to action

Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants

PURPOSE

Holistic review (HR) considers applicants' unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS).

METHODS

Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) [2015-2017] were compared to HR [2018-2022]. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate.

RESULTS

For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR.

CONCLUSION

Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort.

LEVEL OF EVIDENCE

IV.

Current state of inclusion and diversity in pediatric urology fellowship programs

BACKGROUND

Increased racial/ethnic diversity of the physician workforce can improve health outcomes for marginalized populations. Currently, the pediatric urology workforce is less racially/ethnically diverse than the pediatric population it serves.

OBJECTIVE

We aimed to assess current recruitment efforts and barriers to recruitment of underrepresented in medicine (URM) fellows in pediatric urology fellowship programs.

METHODS

A 20-question REDCap survey was created and distributed to 27 pediatric urology fellowship program directors (PDs). The survey consisted of 4 sections of questions focused on PD demographics, program characteristics, recruitment efforts, and perceptions of barriers to recruitment.

RESULTS

A total of 20 PDs responded to the survey (74 %), including 3 incomplete responses. A majority of participants identified as Caucasian/white (79 %), male (68 %), over 40 years of age (89 %), and had served as PD for 5 years or more (68 %). Most PDs (70 %) identified their program having 5-10 full-time pediatric urologists. Many PDs (75 %, 15/20) identified their program as less diverse than the patient population served, and 53 % (9/17) reported having no methods in place for diversity recruitment. Of those who reported a recruitment method, mentorship was the most common (35 %, 6/17). When asked about recruitment barriers, 59 % (10/17) reported that no barriers existed, while those who identified a barrier most commonly cited an overall limited applicant pool (18 %, 3/17).

DISCUSSION

Pediatric urology fellowship programs are less diverse than the patient populations served; while PDs value program diversity, most PDs report that there are no mechanisms in place to recruit racially/ethnically diverse trainees. To address this, we recommend active and intentional efforts to increase URM recruitment in pediatric urology. By taking an active role in existing recruitment efforts, pediatric urologists can increase their visibility, broadcast their commitment to diversity, form relationships with trainees earlier in training and increase opportunities for mentorship and early exposure to the field.

CONCLUSION

Intentional recruitment efforts are needed to recruit URM trainees to pediatric urology fellowship programs and ensure the diversity of the pediatric urology workforce can better reflect patients served.

Language Differences by Race on Letters of Recommendation for the Pediatric Surgery Match

OBJECTIVE

This study aims to evaluate if there is any significant linguistic difference in LoR based on applicant's race/ethnicity.

DESIGN

Retrospective review of applications to pediatric surgery fellowship at a single institution (2016-2020). Race was self-reported by applicants. LoR were analyzed via the Linguistic Inquiry and Word Count (LIWC) software program.

SETTING

Johns Hopkins All Children's Hospital, St. Petersburg, Florida USA. A free-standing tertiary pediatric hospital.

PARTICIPANTS

Pediatric surgery fellowship applicants from 2016 to 2020.

RESULTS

A total of 1086 LoR from 280 applicants (52% female) were analyzed. Racial distribution was Caucasians 62.1%, Asian 12.1%, Hispanics 7.1%, multiracial 6.4% African Americans 5%, and other/unknown 7.1%. Letter writers were largely male (84%), pediatric surgeons (63%) and professors (57%). There was no difference in LoR word count across races. LoR for female multiracial candidates contained higher use of affiliation and negative emotion terms compared to Hispanic females (p = 0.002 and 0.048, respectively), and past focus terms when compared to Caucasian and Asian female applicants (p < 0.001 and p = 0.003, respectively). Religion terms were more common in LoR for Asian females when compared to Caucasian females (p < 0.001).

CONCLUSION

This study demonstrates linguistic differences in LoR for pediatric surgery training programs based on applicant race/ethnicity. While differences are present, these do not suggest overt bias based on applicants race or ethnicity.

Assessing Trends in Supply and Demand for Pediatric Surgery Training

OBJECTIVE

This study assessed the supply and demand for Pediatric Surgery training in the U.S. from 2008 to 2022. We hypothesized that in the Pediatric Surgery Match: match rates would increase over time; U.S. MD Graduates would have higher match rates than non-U.S. MD Graduates; and fewer applicants would match at one of their top fellowship choices.

DESIGN

This was a retrospective cohort study of Pediatric Surgery Match applicants (2008-2022). Cochran-Armitage tests elucidated temporal trends and chi square tests compared outcomes by applicant archetype.

SETTING

Accreditation Council for Graduate Medical Education (ACGME)-accredited Pediatric Surgery training programs in the United States and non-ACGME-accredited programs in Canada.

PARTICIPANTS

A total of 1,133 applicants for Pediatric Surgery training.

RESULTS

From 2008 to 2012, growth in the annual number of fellowship positions (34-43, 27% increase) exceeded growth in number of applicants (62-69, 11% increase) (p < 0.001). Over the study period, the applicant-to-training ratio peaked at 2.1 to 2.2 in 2017 to 2018 and decreased to 1.4 to 1.6 in 2021 to 2022. The annual match rate for U.S. MD Graduates increased from 60% to 68% (p < 0.05), but decreased from 40% to 22% (p < 0.05) for non-U.S. MD Graduates. In 2022, there was a 3.1-fold difference in match rates between U.S. MD and non-U.S. MD Graduates (68% vs 22%, p < 0.001). The percentage of applicants that matched at their first choice (25%-20%, p < 0.001), second choice (11%-4%, p < 0.001), and third choice (7%-4%, p < 0.001) fellowships decreased over the study period. The percentage of applicants that matched at their fourth choice to least desirable fellowship increased from 23% to 33% (p < 0.001).

CONCLUSIONS

The demand for Pediatric Surgery training peaked in 2017 to 2018 and has decreased since. However, the Pediatric Surgery Match remains competitive especially for non-U.S. MD Graduates. More research is needed to understand barriers to matching into Pediatric Surgery for non-U.S. MD Graduates.

Achieving Equity in Organ Transplantation: Recommendations for Action Based on the National Academies of Sciences, Engineering, and Medicine Report

The United States organ transplantation system has recently reached a historic milestone of a cumulative 1 million transplants. Despite this considerable success in providing life-saving organ transplants to patients with end organ failure, there are ample opportunities for improvement, particularly with regard to achieving equity. Recognizing this, Congress directed the National Institutes of Health to fund the National Academies of Sciences, Engineering, and Medicine in conducting a study on deceased donor organ procurement, allocation, and distribution, recommending ways to improve equity and accountability. The National Academies of Sciences, Engineering, and Medicine study committee's report, Realizing the Promise of Equity in the Organ Transplantation System , reached multiple conclusions and agreed on 14 recommendations for action that can be grouped into 3 areas: (1) achieving equity, (2) improving system performance, and (3) increasing the utilization of available organs. Here, we review overarching areas for improvement, highlighting key recommendations, and suggest implementing actions.