Analysis of Electronic Residency Application Service (ERAS) Data Can Improve House Staff Diversity

Gender, Race, and Ethnicity in Critical Care Fellowship Programs in the United States From 2016 to 2021

A diverse and inclusive critical care workforce is vital to the provision of culturally appropriate and effective care to critically ill patients of all backgrounds.

OBJECTIVES

The purpose of this study is to determine the trends in gender, race, and ethnicity of U.S. critical care fellowships over the past 6 years (2016-2021).

METHODS

Data on gender, race, and ethnicity of critical care fellows in five Accreditation Council on Graduate Medical Education-accredited training programs (internal medicine, pulmonary and critical care, anesthesiology, surgery, and pediatrics) from 2015 to 2016 to 2020-2021 were obtained from the joint reports of the American Medical Association (AMA) and Association of American Medical Colleges published annually in the Journal of the AMA.

RESULTS

From 2016 to 2021, the number of U.S. critical care fellows increased annually, up 23.8%, with the largest number of fellows in pulmonary critical care medicine (60.1%). The percentage of female critical care fellows slightly increased from 38.7% to 39.4% (p = 0.57). White fellows significantly decreased from 57.4% to 49.3% (p = 0.0001); similarly, Asian fellows significantly decreased from 30.8% to 27.5% (p = 0.004). The percentage of Black or African American fellows was not statistically significantly different (4.9% vs 4.4%; p = 0.44). The number of fellows who self-identified as multiracial significantly increased from 52 (1.9%) to 91 (2.7%) (p = 0.043). The percentage of fellows who identified as Hispanic was not significantly different (6.7% vs 7.5%; p = 0.23).

CONCLUSIONS

The percentage of women and racially and ethnically minoritized fellows (Black and Hispanic) remain underrepresented in critical care fellowship programs. Additional research is needed to better understand these demographic trends in our emerging critical care physician workforce and enhance diversity.

Interventions Associated With Racial and Ethnic Diversity in US Graduate Medical Education: A Scoping Review

IMPORTANCE

Racially and ethnically minoritized individuals remain underrepresented in graduate medical education relative to their proportion in the population. While many programs and initiatives have been developed to address this problem, there is little consensus regarding strategies that work to improve representation across specialties.

OBJECTIVE

To examine and synthesize evidence-based practices that have been used to increase the proportions of underrepresented in medicine (URiM) trainees at US residency and fellowship programs.

EVIDENCE REVIEW

The authors searched PubMed, Google Scholar, Embase, PsycInfo, ERIC, Cochrane Reviews, Cochrane Trials, CINAHL, Scopus, and PROSPERO electronic databases to identify relevant studies published through January 2022. They screened all titles and abstracts for relevance and read full-text articles to identify articles reporting reliable data describing the outcomes of interventions to improve racial and ethnic diversity among trainees.

FINDINGS

Twenty-seven articles were included in this review. Two studies reported on fellowship programs. The most common interventions included holistic review (48%), decreased emphasis on United States Medical Licensing Examination Step 1 scores (48%), and explicit institutional messaging regarding the importance of diversity (37%). A combination of interventions was associated with an increased number of URiM applicants, interviewees, and matriculants across various medical and surgical specialties.

CONCLUSIONS AND RELEVANCE

In this scoping review, approaches and interventions associated with increased diversity in residency and fellowship programs were identified. Continued efforts are necessary to sustain such efforts and assess long-term outcomes.

Advancing Equity in Graduate Medical Education Recruitment Through a Diversity Equity and Inclusion (DEI) Toolkit for Program Directors

Objectives

To increase diversity and inclusion in graduate medical education (GME), the Accreditation Council for Graduate Medical Education (ACGME) issued new diversity standards requiring programs to engage in practices that focus on systematic recruitment and retention of a diverse workforce of trainees and faculty. The literature on how program directors (PDs) can incorporate and prepare for this standard is limited.

Methods

We developed a diversity, equity, and inclusion (DEI) toolkit for PDs as an example of an institutional GME-led effort to promote inclusive recruitment and DEI awareness among residency and fellowship programs at a large academic center.

Results

A survey was sent to 80 PDs before the launch of the toolkit and 6 months afterwards with response rates of 27% (22/80) and 97% (78/80), respectively. At baseline, 45% (10/22) anticipated that the DEI toolkit might provide better resources than those currently available to them and 41% (9/22) perceived that the toolkit might improve recruitment outcomes. At 6 months, 63% (49/78) found the toolkit helpful in the 2021-2022 recruitment season. By contrast, 2% (2/78) of PDs did not find the toolkit helpful, and 33% (26/78) said they did not access the toolkit. When asked if a PD changed their program's recruitment practices because of the toolkit, 31% (24/78) responded yes. Programs that changed recruitment practices started to require unconscious bias training for all faculty and residents involved in the residency interviews and ranking. Others worked on creating a standardized scoring rubric for interviews focused on four main domains: Experiences, Attributes, Competencies, and Academic Metrics.

Conclusion

There is a need to support PDs in their DEI journey and their work to recruit a diverse workforce in medicine. Utilizing a DEI toolkit is one option to increase DEI knowledge, skills, awareness, and self-efficacy among PDs and can be adopted by other institutions and leaders in academic medicine.

Underrepresented in medicine in graduate medical education: Historical trends, bias, and recruitment practices

Health inequities disproportionately impact children of color in the United States. Research demonstrates that a diverse physician workforce that reflects the demographic profile of the United States population has been associated with better health outcomes and physicians of color are more likely to work in communities that are medically underserved. Therefore, a key driver to reducing health inequities is recruiting a physician workforce that reflects the racial/ethnic composition of the population. Although efforts on increasing UIM applicants and matriculants into medical school and more recently, graduate medical education (GME) programs have shown some small successes, there has still not been significant change in decades. This narrative review examined the historical trends and current landscape of recruitment in GME to better understand the barriers and facilitators that continue to exist and identify successful interventions that might serve as a model to support recruitment of UIM applicants. There is evidence for racial disparities and bias in traditional residency selection metrics (USMLE, Clerkship Evaluations, MSPE, AOA status, etc.) and a need for more holistic recruitment strategies. Along with implementing new holistic recruitment practices, there is a need for ongoing research and collaboration to study inclusive and equitable learning environments and assessments that will eliminate racial disparities in educational outcomes. Additionally, there must be better longitudinal data utilization and transparency across Electronic Residency Application Services (ERAS) and National Resident Matching Program (NRMP) for accountability and tracking of interventions.