Physician Workforce Disparities and Patient Care: A Narrative Review

The experiences of culturally and linguistically diverse health practitioners in dominant culture practice: a scoping review

Increasing the proportion of culturally and linguistically diverse (CALD) health practitioners is identified as one strategy to address healthcare disparities that individuals from minority or under-represented backgrounds experience. However, professional and institutional cultures and structures are known to contribute to the challenges for CALD practitioners who work in dominant culture practice contexts. This scoping review used the theory of Legitimate Peripheral Participation to describe and interpret literature about the experiences of CALD health practitioners in view of informing strategies to increase their representation. A systematised search was conducted across four allied health, medicine and nursing databases. Following abstract and full text screening, articles which fit the inclusion criteria (n = 124) proceeded to data extraction. Categories relating to the experiences of practitioners were extracted, and three themes were identified that were subsequently theoretically interpreted: Discrimination, Consequences and Hierarchy. Discrimination functioned as a barrier to CALD practitioners being legitimised and able to participate equally in healthcare practice, retaining their position at the periphery of the practice community; Consequences reinforced this peripheral position and further impeded legitimation and participation; and Hierarchy was maintained through structures that reinforced and reproduced these barriers. The findings summarise how these barriers are reinforced through the intersections of professional and racial hierarchies, and highlight a need for strategies to address discrimination and structures that marginalise CALD practitioners' identity, practices and participation in their health professional communities.

Just-in-Time Strategies to Reduce the Effect of Interviewer Bias During Trainee Recruitment

Bias impacts all aspects of medical trainee applications, from grades to narrative reviews. Interviews provide an avenue to become acquainted with applicants beyond their written application, but even the most egalitarian interviewers are subject to implicit biases, including those who hold marginalized identities themselves. Simply building awareness around implicit bias is inadequate to reduce the effect. Here, 5 evidence-informed strategies are presented that can be implemented by faculty on-the-spot to mitigate the impact of implicit bias during the short interview interaction: individuation, mindfulness, perspective taking, stereotype replacement, and counter-stereotypic imaging. These strategies can be used by individual interviewers as one component of a comprehensive plan including institutional changes to promote more equitable recruitment processes.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

BACKGROUND

Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication.

METHODS

In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses.

RESULTS

The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04).

CONCLUSIONS

These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce.

CLINICAL RELEVANCE

This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

Leaning in and moving forward: a call to action and review of diversity initiatives in SAGES

BACKGROUND

Diversity, equity, and inclusion have been an intentional focus for SAGES well before the COVID-19 pandemic and the coincident societal recognition of social injustices and racism. Longstanding inequities within our society, healthcare, and the surgery profession have come to light in the aftermath of events that rose to attention around the time of Covid. In so doing, they have brought into focus disparities, injustices, and inequalities that have long been present in the field of surgery, selectively affecting the most vulnerable.

METHODS

This White paper examines the current state of diversity within the field of surgery and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) approach and effort to pave the way forward to meaningful change. We delineate the imperative for diversity, equity, and inclusion for all. By all, we mean to be inclusive of the diversity of gender and sexual orientation, race, ethnicity, geography, sex, and disability in the field of surgery.

RESULTS

SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric.

CONCLUSION

True diversity, equity, and inclusion within a surgical organization is vital for its longevity, growth, relevance, and impact. Unfortunately, the absence of DEI limits opportunity, robs the organization of collective intelligence in an environment in which its presence is critical, contributes to health inequities, and impoverishes all within the society and its value to all with whom it interfaces. SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric. Strategies like those highlighted in this White Paper, may be within our grasp and we can learn yet more if we remain in a place of humility and teachability in the future.

How early clinical experiences in rural communities influence student learning about rural generalism considered through the lens of educational theory

Introduction

Rural communities have poorer health compared to urban populations due partly to having lesser healthcare access. Rural placements during medical education can equip students with the knowledge and skills to work in rural communities, and, it is hoped, increase the supply of rural physicians. It is unclear how students gain knowledge of rural generalism during placements, and how this can be understood in terms of place-based and/or sociocultural educational theories. To gain insight into these questions we considered the experiences of pre-clerkship medical students who completed two mandatory four-week rural placements during their second year of medical school.

Methods

Data was collected using semi-structured interviews or focus groups, followed by thematic analysis of the interview transcripts.

Results

Rural placements allowed students to learn about rural generalism such as breadth of practice, and boundary issues. This occurred mainly by students interacting with rural physician faculty, with the effectiveness of precepting being key to students acquiring knowledge and skills and reporting a positive regard for the placement experience.

Discussion

Our data show the central role of generalist physician preceptors in how and what students learn while participating in rural placements. Sociocultural learning theory best explains student learning, while place-based education theory helps inform the curriculum. Effective training and preparation of preceptors is likely key to positive student placement experiences.

Implementing a Holistic Review Process for Psychiatry Residency Screening and Interviewing

Within psychiatry, the proportions of individuals underrepresented in medicine (URM) are lower than are the proportions among the general U.S. population. Holistic review of residency applications may alleviate deficiencies in representation and disparities in care.  A holistic review process was implemented (2021-2022) in the University of California, San Diego, psychiatry residency program. The data (2016-2022) were extracted from the Electronic Residency Application Service to compare differences in the applicant pool before and after implementation of the holistic review.  A total of 6,602 individuals applied to the program between 2016 and 2022, increasing from 762 in 2016 to 1,148 in 2021. The proportion of women applying significantly increased (χ2=12.6, p<0.002), from 42.3% in 2016 to 50.6% in 2022. Across all years, a significantly greater proportion (χ2=22.0, p<0.001) of those selected to interview were women (55.1%), with the greatest proportion in 2022 (64.5%), after implementation of the holistic review. The proportion of applicants from URM groups significantly increased (χ2=28.0, p<0.001), from 13.4% in 2016 to 21.3% in 2022. There were no significant differences in the proportion of these applicants selected to interview across all years and no increase following the holistic review.  The proportion of women interviewed was greater than the proportion of women who applied, particularly after implementing the holistic review. The proportion of applicants from URM groups increased over time and, although the proportion interviewed remained greater than the number applying, that number did not change across the years studied.

Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study

OBJECTIVE

To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery.

BACKGROUND

Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics.

RESULTS

Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)].

CONCLUSIONS

Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.

Acceptance of Students with Physical Disabilities in Medical Schools in Saudi Arabia: Perception, Experience, and Recommendation

Introduction

Physical disability is seen as a burden in many countries, and it has been a challenge to create a healthy environment and a fair living experience for all people with physical disability. For a long time, the number of students accepted to medical school has been limited, and the number of successful experiences for doctors with disabilities is inadequate worldwide. This study aims to investigate the perception of the public, medical educators, and medical students about the acceptance of students with physical disabilities in medical schools in Saudi Arabia.

Methods

The study uses two methodological strategies: a quantitative cross-sectional survey and a qualitative interview with a young female doctor with a physical disability to discuss her educational experience and work journey in Saudi Arabia and abroad. The study was conducted at the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Results

The perception survey results showed a broad acceptance of the public, medical educators, and medical students regarding the enrollment of students with physical disabilities in medical schools and regarding being treated by doctors with physical disabilities. The participants also believed that students with physical disabilities are compatible with most doctors' jobs.

Conclusion

Students with physical disabilities should be able to study and practice medicine. Educational and health institutions should apply more effort and commitment to provide the necessary accommodations to accept students and doctors with physical disabilities based on their cognitive ability but not their physical disability.

Are our actions matching our words? A review of trainee ethnic and gender diversity in orthopaedic surgery

Background

There is a lack of physician ethnic and gender diversity amongst surgical specialties. This study analyzes the literature that promotes diversity amongst surgical trainees. Specifically, this study sought to answer (i) how the number of publications regarding diversity in orthopaedic surgery compares to other surgical specialties, (ii) how the number of publications amongst all surgical subspecialties trends over time and (iii) which specific topics regarding diversity are discussed in the surgical literature.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to query articles from PubMed, Web of Science, Embase and the Cumulative Index to Nursing and Allied Health Literature. Broad inclusion criteria for both ethnic and gender diversity of any surgical specialty were utilized.

Results

Our query resulted 1429 publications, of which 408 duplicates were removed, and 701 were excluded on title and abstract screening, leaving 320 to be included. The highest number of related publications was in orthopaedic surgery (n = 73) followed by general surgery (n = 56). Out of 320 total articles, 260 (81.3 %) were published after 2015, and 56 of 73 (76.7 %) orthopaedic-specific articles were published after 2015.

Conclusion

Orthopaedic surgery published the most about ethnic and gender diversity, however, still remains one of the least diverse surgical specialties. With the recent increase in publications on diversity in surgical training, close attention should be paid to ethnic and gender diversity amongst surgical trainees over the coming years. Should diversity remain stagnant, diversification efforts may need to be restructured to achieve a diverse surgeon workforce.

Key message

Orthopaedic surgery is the surgical subspecialty that publishes the most about trainee ethnic and gender diversity followed by general surgery. With most of this literature being published over the last eight years, it is imperative to pay close attention to the ethnic and gender landscape of the surgeon workforce over the coming years.

Examining Diversity Recruitment Efforts in US-Based Physical Medicine and Rehabilitation Residencies: A Survey of Program Directors on Gender, Ethnic and Racial Diversity, and Implications for Recruitment Efforts

As the population of the United States continues to grow and diversify, it is critical that the medical profession follows. This study aimed to evaluate aspects of the current landscape of diversity within physical medicine and rehabilitation by surveying program directors of US-based physical medicine and rehabilitation residencies. The secondary aim was to identify program characteristics that correlate with more diverse residency classes. An online, cross-sectional 17-question survey was distributed to program directors of all US-based physical medicine and rehabilitation residencies with known contact information (95/100), with a completed survey response rate of 53% (50/95). Race and ethnicity categories of the survey were based on those used by the US Census. The percentages of individuals identifying as women or those underrepresented in medicine in this survey were below those of the general US population, a trend also seen within the field of physical medicine and rehabilitation overall. Linear regression revealed no statistically significant association between the percentage of underrepresented in medicine residents and commonly used diversity recruitment initiatives. There was a significant association between the presence of a departmental role for diversity, equity and inclusion and the percentage of women residents (odds ratio, 1.13; P = 0.017). Continued research is required to identify additional strategies with demonstrated efficacy in recruiting diverse residency applicants.

Workforce Diversity, Equity, and Inclusion: A Crucial Component of Professionalism in Psychiatry

Documented disparities have profoundly impacted the training and careers of physicians from socially and historically marginalized groups, including women, people with disabilities, people who identify with racial and ethnic minority groups, and the lesbian, gay, bisexual, transgender, and queer or questioning+ community. Professionalism is a core component of medical training and practice, yet a focus on workforce diversity, equity, and inclusion is often absent. This report aims to encourage the adoption of workforce diversity, equity, and inclusion as a crucial component of professionalism, with an emphasis on the field of psychiatry.

Changing the Clock in Medical Education: Addressing Physician Shortages and Patient Outcomes

Despite the shortage of physicians in the United States, there is no consensus among medical educators as to how to address the nation's unmet needs. A growing but unfulfilled argument is to revisit the configuration of medical education and the time required to complete medical training. Pilot programs, such as shortened programs or advancement-in-place structures to accelerate the practice capability of trainees, have been attempted. This manuscript addresses underlying economic and human considerations that medical educators must reconcile, drawing on lessons from international educational structures, as we advance toward a system that supports the needs of the communities that our graduates will serve.

At the Intersection of Intersectionality: Race and Gender Diversity Among Surgical Faculty and Trainees

OBJECTIVE

To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students.

BACKGROUND

Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity.

METHODS

Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students.

RESULTS

Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001).

CONCLUSIONS

URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students.

The 2021 ACR/Radiology Business Management Association Workforce Survey: Diversity in Radiology

The landscape of the radiology workforce is changing, especially in the diversity of the demographics of practicing radiologists across subspecialties, practice types, and leadership positions in both academic and nonacademic settings. The 2021 ACR/Radiology Business Management Association Workforce Survey examines these facets in detail and contributes to our understanding of the current state of diversity in the radiology workforce and potential barriers to change. The results suggest opportunities and future directions for improving diversity, equity, and inclusion.

Diversity in interventional radiology: Survey of medical student interest with focus on women and members of underrepresented in medicine racial and ethnic groups

PURPOSE

To assess: 1) the percentage of female and underrepresented in medicine (URiM) medical students interested in interventional radiology (IR), and 2) the motivations for and deterrents from IR for female and URiM students.

METHODS

The study was IRB exempt. Data from a 19-item survey sent to 5 US medical schools were collected from 10/2018-01/2019 using REDCap and analyzed with SAS GLIMMIX.

RESULTS

16% (56/346) of women and 27% (69/258) of men strongly considered IR. 21% (19/89) of URiM versus 21% (105/508) of non-URiM students, p = .88, seriously considered IR. On a 0-to-4 scale (0 = not a motivator, 4 = strong motivator), women rated "Female mentorship" "2.5" versus males' "0.4", p < .0001, independent of IR interest URiM students uninterested in IR rated "Lack of ethnic diversity in training""2.3" versus "1.2" for IR-interested URiM, p < .01. 18% (9/50) of IR-interested women reported adequate gender-specific mentorship in IR in medical school. Of IR-interested URiM students 5% (1/19) reported adequate ethnicity/race-specific mentorship.

CONCLUSION

Fewer female medical students considered IR compared to males. Female mentorship was a significant motivator for women. Similar numbers of URiM and non-URiM students consider IR. Few women and URiM students report adequate gender/ethnicity/race-specific mentorship. For students not interested in IR, lack of ethnic diversity in training was a significant deterrent. Increasing numbers and visibility of female and URiM interventional radiologists in mentoring and clinical practice may improve recruitment of medical students from these underrepresented groups.

'First in family' experiences in a Canadian medical school: A critically reflexive study

BACKGROUND

Medical students from affluent and highly educated backgrounds remain overrepresented in Canadian medical schools despite widespread efforts to improve diversity. Little is known of the medical school experiences of students who are first in their family (FiF) to attend university. Drawing on Bourdieu and a critically reflexive lens, this study explored the experiences of FiF students in a Canadian medical school to better understand the ways in which the medical school environment can be exclusive and inequitable to underrepresented students.

METHODS

We interviewed 17 medical students who self-identified as being FiF to attend university. Utilising theoretical sampling, we also interviewed five students who identified as being from medical families to test our emerging theoretical framework. Participants were asked to discuss what 'first in family' meant to them, their journey into medical school and their experiences at medical school. Bourdieu's theories and concepts were used as sensitising concepts to explore the data.

RESULTS

FiF students discussed the implicit messages they received about who belongs in medical school, challenges in shifting from their pre-medical lives to a medical identity and competing with peers for residency programmes. They reflected on the advantages they perceived they had over their fellow students due to their less 'typical' social backgrounds.

CONCLUSION

While medical schools continue to make strides when it comes to increasing diversity, inclusivity and equity require increased attention. Our findings highlight the ongoing need for structural and cultural change at admissions and beyond-change that recognises the much-needed presence and perspectives that underrepresented medical students, including those who are FiF, bring to medical education and healthcare. Engaging in critical reflexivity represents a key way that medical schools can continue to address issues of equity, diversity and inclusion.

Diversity of Leadership and Its Influence on Diversity of Integrated Plastic Surgery Residency Cohorts: A Study in the Virtual Era

Background

In the aftermath of COVID-19, the residency application process has largely remained in the virtual space, introducing a new challenge to prospective integrated plastic surgery residents. Many programs enhanced their online presence to address this challenge, but both programs and applicants are still limited to a virtual snapshot when determining "fit." An important influence of fit is the ability to racially, ethnically, and/or culturally identify with the program. The aims of this study are to: (1) better understand the online information that residency programs are making available to prospective applicants, (2) characterize the racial diversity of programs, and (3) investigate the effect of program leadership on racial diversity.

Methods

A cross-sectional study of US integrated plastic surgery residency programs was performed in August 2022. Data on race were collected for residency program directors and resident cohorts and compared with self-reported data from the Association of American Medical Colleges (AAMC). Relationships between these groups were analyzed.

Results

Racial data were collected on 82 program directors and their corresponding residency cohorts, representing a total of 1174 individuals. These data closely matched the AAMC data on race/ethnicity in plastic surgery programs. By race, the smallest percentage of resident groups are Black/African American (3.4%) and Hispanic (4.2%). Though not statistically significant, more residents of a given race are in programs with a director of the same race.

Conclusions

Online information about residency programs and their cohorts is robust. The racial diversity of a residency cohort is positively associated with racial diversity of program directors.

Healthcare Experiences of African American Women with the Fragile X Premutation

This study aims to understand the healthcare experiences of African American women with a fragile X premutation (PM). PM carriers are at risk for fragile X-associated conditions, including primary ovarian insufficiency (FXPOI) and neuropsychiatric disorders (FXAND). There is no racial/ethnic association with carrying a PM, but African American women historically experience barriers receiving quality healthcare in the USA. Obstacles to care may increase mental health conditions like anxiety and depression. Eight African American women with a PM were interviewed to explore disparities in receiving healthcare and to learn about psychosocial experiences during and after their diagnoses. Interviews were transcribed verbatim and independently coded by two researchers. A deductive-inductive approach was used, followed by thematic analysis to determine prominent themes. The average participant age was 52.3 ± 8.60 years, with a mean age at premutation diagnosis of 31 ± 5.95 years. Seven participants had children with FXS. Themes from interviews included healthcare experiences, family dynamics, and emotional/mental health after their diagnosis. Participants reported concerns about not being taken seriously by providers and mistrust of the medical institutions. Within families, participants reported denial, insensitivity, and isolation. Participants reported a high incidence of anxiety and depression. Both are symptoms of FXAND and stresses of systemic racism and sexism. The reported family dynamics around the news of a genetic diagnosis stand apart from other racial cohorts in fragile X research: interventions like family counseling sessions and inclusive support opportunities from national organizations could ease the impacts of a PM for African American women.

Prevalence of Diversity Statements and Disability Inclusion Among Radiology Residency Program Websites

INTRODUCTION

Radiology has widely acknowledged the need to improve inclusion of racial, ethnic, gender, and sexual minorities, with recent discourse also underscoring the importance of disability diversity and inclusion efforts. Yet studies have shown a paucity of diversity among radiology residents, despite increasing efforts to foster diversity and inclusion. Thus, the purpose of this study is to assess radiology residency program websites' diversity statements for inclusion of race and ethnicity, gender, sexual orientation, and disability as commonly underrepresented groups.

METHODS

A cross-sectional, observational study of websites of all diagnostic radiology programs in the Electronic Residency Application Service directory was conducted. Program websites that met inclusion criteria were audited for presence of a diversity statement; if the statement was specific to the residency program, radiology department, or institution; and if it was presented or linked on the program or department website. All statements were evaluated for the inclusion of four diversity categories: race or ethnicity, gender, sexual orientation, and disability.

RESULTS

One hundred ninety-two radiology residencies were identified using Electronic Residency Application Service. Programs with missing or malfunctioning hyperlinks (n = 33) or required logins (n = 1) were excluded. One hundred fifty-eight websites met inclusion criteria for analysis. Two-thirds (n = 103; 65.1%) had a diversity statement within their residency, department, or institution, with only 28 (18%) having residency program-specific statements and 22 (14%) having department-specific statements. Of the websites with diversity statements, inclusion of gender diversity was most frequent (43.0%), followed by race or ethnicity (39.9%), sexual orientation (32.9%), and disability (25.3%). Race or ethnicity was most included in institution-level diversity statements.

CONCLUSIONS

Less than 20% of radiology residency websites include a diversity statement, and disability is the least-included category among the diversity statements. As radiology continues to lead diversity and inclusion efforts in health care, a more comprehensive approach with equitable representation of different groups, including those with disabilities, would foster a broader sense of belonging. This comprehensive approach can help to overcome systemic barriers and bridge gaps in disability representation.

Abortion Provision Among Family Physicians Underrepresented in Medicine

BACKGROUND AND OBJECTIVES

Workforce diversity in primary care is critical for improved health outcomes and mitigation of inequities. However, little is known about the racial and ethnic identities, training histories, and practice patterns of family physicians who provide abortions.

METHODS

Family physicians who graduated from residency programs with routine abortion training from 2015 through 2018 completed an anonymous electronic cross-sectional survey. We measured abortion training, intentions to provide abortion, and practice patterns, and examined differences between underrepresented in medicine (URM) and non-URM physicians using χ2 tests and binary logistic regression.

RESULTS

Two hundred ninety-eight respondents completed the survey (39% response rate), 17% of whom were URM. Similar percentages of URM and non-URM respondents had abortion training and had intended to provide abortions. However, fewer URMs reported providing procedural abortion in their postresidency practice (6% vs 19%, P=.03) and providing abortion in the past year (6% vs 20%, P=.023). In adjusted analyses, URMs were less likely to have provided abortions after residency (OR=.383, P=.03) and in the past year (OR=.217, P=.02) compared to non-URMs. Of the 16 noted barriers to provision, few differences were evident between groups on the indicators measured.

CONCLUSIONS

Differences in postresidency abortion provision existed between URM and non-URM family physicians despite similar training and intentions to provide. Examined barriers do not explain these differences. Further research on the unique experiences of URM physicians in abortion care is needed to then consider which strategies for building a more diverse workforce should be employed.

Intersectionality: Understanding the Interdependent Systems of Discrimination and Disadvantage

The fight for gender equity in surgery extends well beyond the simplistic binary construct of man versus woman. Professor Kimberlé Crenshaw coined the term "intersectionality," which is used to describe the dynamic associations between the concepts of race, class, gender, and other individualized characteristics and their real-time interaction with one another in our society. Our review of intersectional identities among medical professionals attempts to examine the trends of difficulties at the intersections of an individual's identity within academic surgery, leadership in academic surgery, and the effects on patient outcomes in the United States. Specifically, we will focus on the interaction of race, ethnicity, religion, sexual orientation, family, disability, and international status. Much more research focused specifically on intersectional groups is required to statistically identify to what degree overlapping identities impact professional and patient care outcomes. Recognition of the problem and candid discussions will allow for vast improvements not only in surgical culture, but also in surgical care.

Navigating Minority and Gender Discrimination, Substance Use Disorder, Financial Distress, and Workplace Politics: Lessons for Work-Life Wellness in Academic Medicine: Part 2 of 3

In this second of three manuscripts addressing a range of complex work and personal issues, the authors explore case scenarios with characters who work in the fields of general surgery, orthopedic surgery, anesthesiology, neurology, radiology, and otolaryngology. The medical specialty identifiers help inform some baseline understanding of the demands of that particular profession but are less pertinent than the specifics of each case. In this manuscript, the authors dive into the topics of navigating a lawsuit and professional burnout, personal finances, substance use disorder, demands of clinical work and workplace politics, diversity and inclusion, and dealing with major personal illness. The authors provide practical steps to help the readers deal with similar situations and provide insight to support persons on how to improve support structures.

Exploring Diversity in Otolaryngology-Head and Neck Surgery Journal Editorial Boards

OBJECTIVE

Despite increasing diversity in medical school entrants, disparities exist in academic leadership. This study sought to examine the proportion of women and visible minorities (VMs) among editorial board members (EBMs) of otolaryngology journals.

METHODS

Two reviewers collected journal, editorial board, and editor-in-chief characteristics using journal mastheads or official websites. Gender and VM representation on editorial boards and factors associated with increased representation were investigated.

RESULTS

Forty-one journals were explored, from January to April 2022. Of 2128 EBMs, 663 (31.3%) were VMs and 551 (25.9%) were women. Editor-in-chief roles were held by 12 (25%) VM individuals and 3 (6.2%) women. Gender differences in the distribution of editorial board positions were found (P < .001); women had higher representation as associate editors (24.5%, n = 551 vs 15.4, n = 1577%) and deputy/managing editors (2.2%, n = 551 vs 0.4%, n = 1577), while men were more represented as editor-in-chief (2.9%, n = 1577 vs 0.5%, n = 551). Similar VM representation existed between genders (31.0% male; 31.6% women) (P = .80). Journal impact factor quartile and gender were significantly correlated (P < .001); a higher proportion of women were represented in the first (27.0% vs 24.5%) and fourth (12.0% vs 4.9%) quartile. No significant factors were identified for higher women's editorial board representation. Larger editorial board size (P = .002) and Asian/South American journals (P = .003 to P < .001) had significantly higher representation of VMs.

CONCLUSION

Women and VMs are underrepresented in high-ranking editorial positions. Diversity in editorial boards is needed to ensure fair and balanced journal reviews and equity within otolaryngology.

Disability, program access, empathy and burnout in US medical students: A national study

OBJECTIVE

The objective of this study is to investigate whether self-disclosed disability and self-reported program access are associated with measures of empathy and burnout in a national sample of US medical students.

METHODS

The authors obtained data from students who responded to the Association of Medical Colleges (AAMC) Year 2 Questionnaire (Y2Q) in 2019 and 2020. Data included demographic characteristics, personal variables, learning environment indicators, measures of burnout (Oldenburg Burnout Inventory for Medical Students), empathy (Interpersonal Reactivity Index) and disability-related questions, including self-reported disability, disability category and program access. Associations between disability status, program access, empathy and burnout were assessed using multivariable logistic regression models accounting for YQ2 demographic, personal-related and learning environment measures.

RESULTS

Overall, 23 898 (54.2%) provided disability data and were included. Of those, 2438 (10.2%) self-reported a disability. Most medical students with disabilities (SWD) self-reported having program access through accommodations (1215 [49.8%]) or that accommodations were not required for access (824 [33.8%]). Multivariable models identified that compared with students without disabilities, SWD with and without program access presented higher odds of high exhaustion (1.50 [95% CI, 1.34-1.69] and 2.59 [95% CI, 1.93-3.49], respectively) and lower odds of low empathy (0.75 [95% CI, 0.67-.85] and 0.68 [95% CI, 0.52-0.90], respectively). In contrast, multivariable models for disengagement identified that SWD reporting lack of program access presented higher odds of high disengagement compared to students without disabilities (1.43 [95% CI, 1.09-1.87], whereas SWD with program access did not (1.09 [95% CI, 0.97-1.22]).

CONCLUSIONS

Despite higher odds of high exhaustion, SWD were less likely to present low empathy regardless of program access, and SWD with program access did not differ from students without disabilities in terms of disengagement. These findings add to our understanding of the characteristics and experiences of SWD including their contributions as empathic future physicians.

Muslim American physicians' experiences with, and views on, religious discrimination and accommodation in academic medicine

OBJECTIVE

To assess Muslim physician experiences with religious discrimination and identify strategies for better accommodating Muslim identity in health care.

DATA SOURCES AND STUDY SETTING

Interviews were conducted with Muslim physicians from three US-based Muslim clinician organizations between June and August 2021.

STUDY DESIGN

In-depth, semi-structured qualitative interviews used a phenomenological approach to describe experiences of religious discrimination and accommodation. A team-based framework approach to coding was used to inductively generate themes from interview data.

DATA COLLECTION/EXTRACTION METHODS

Physicians from the Islamic Medical Association of North America, American Muslim Health Professionals, and the US Muslim Physicians group were invited to participate using closed organizational listservs. Inclusion criteria sought English-speaking, self-identifying Muslims with current or past affiliation with a university hospital in the United States. Potential participants were segmented into groups based on responses to questions about perceived religious discrimination and accommodation. Purposive sampling was used to iteratively approach participants within these groups in order to capture a diverse respondent pool. Interviews stopped after thematic saturation was reached.

PRINCIPAL FINDINGS

Eighteen physicians (11 women and 7 men; mean age: 41.5 [standard deviation = 12.91] years) were interviewed. Nearly all (n = 16) held Islam to be important in their lives. Three overarching themes, with several subthemes, emerged. Participants (1) struggled to maintain religious practices and observances due to unaccommodating organizational structures; (2) experienced religious discrimination, which, in turn, impacted their professional trajectories and, at times, their personal well-being; and (3) believed that institutions could implement specific educational and policy interventions to advance the religious accommodation of Muslims in health care.

CONCLUSIONS

Muslim physicians frequently encounter religious discrimination, yet there are concrete ways in which health care workplaces can better accommodate their religious needs and combat discrimination. To improve workforce diversity, equity, and inclusion, educational forums and policies that support the religious practices of physicians need to be established.

Ethnic and Gender Diversity in Pathology: A Dream Deferred

Background Equity, diversity, and inclusion (EDI) remain an elusive dream in the physician workforce in the United States of America (USA). Many studies have documented the tangible and intangible benefits of EDI, including the caregiver, patients, and healthcare organizations. Objective We aim to examine the ethnic and gender diversity trends of the active residents in pathology in United States residency programs. Methods A retrospective cross-sectional study was conducted on the ethnicity and gender distribution of pathology residency trainees from the academic year 2007-2018. The data was compiled from the American Association of Medical Colleges (AAMC) annual report. Data was entered and analyzed using Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA, USA). Frequencies and percentages were calculated, and bar charts and pie charts were used for graphical representation. Results Almost 35,000 US pathology residents were enrolled according to AAMC during this particular period. The highest trend of enrolling in the field of pathology was observed in 2010 and remained the same for years. This shows that the field of pathology in the USA had some acceptance all these years. The most popular speciality in which most residents were enrolled was anatomic/clinical pathology (80%) in which females were dominant over other fields. Conclusion Over the years, we have failed to overcome gender and ethnicity diversity. Gender and ethnicity have a significant influence on leadership positions, academic ranks, and research productivity among pathology faculty members in the USA.

Virtual Interviews: Outcomes and Lessons Learned

BACKGROUND AND OBJECTIVES

The family medicine residency application process is arduous and competitive. An important part of the application is the in-person interview process, which was affected during the last two interview cycles (2021-2022) due to restrictions imposed by the COVID-19 pandemic. Virtual interviews eliminate traveling costs associated with applications, potentially improving underrepresented minorities' access to interviewing opportunities. Our goal was to assess if virtual interviews at our institution have negative or positive effects on access for underrepresented in medicine (URiM) applicants and our residency match results.   Methods: We analyzed data from 2019-2022 to compare application volumes, applicant demographics, and match results between two in-person cycles (2019 and 2020) and two virtual cycles (2021-2022). Data were analyzed using Pearson χ2 criteria and P=.05 defined significance. Differences between years for expected counts were determined using single sample χ2 tests.  Results: No statistical significance was noted on number of applications by URiM to our program despite decrease costs associated with virtual interview process. The number of URiM applicants matching to our program did not improve by simply implementing virtual interviews when compared to in-person interview seasons in the past.

CONCLUSIONS

Virtual interviews at our institution did not increase URiM applications to our program from substantial equivalent medical schools. Further research in this area from programs in other states may enhance our understanding of the impact of virtual interviews on URiM applications to residency and match results.

Race/Ethnicity and Gender Representation in Hematology and Oncology Editorial Boards: What is the State of Diversity?

INTRODUCTION

Women and underrepresented groups in medicine hold few academic leadership positions in the field of hematology/oncology. In this study, we assessed gender and race/ethnicity representation in editorial board positions in hematology/oncology journals.

MATERIALS AND METHODS

Editorial leadership board members from 60 major journals in hematology and oncology were reviewed; 54 journals were included in the final analysis. Gender and race/ethnicity were determined based on publicly available data for Editor-in-Chief (EiC) and Second-in-Command (SiC) (including deputy, senior, or associate editors). Descriptive statistics and chi-squared were estimated. In the second phase of the study, editors were emailed a 4-item survey to self-identify their demographics.

RESULTS

Out of 793 editorial board members, 72.6% were men and 27.4% were women. Editorial leadership were non-Hispanic white (71.1%) with Asian editorial board members representing the second largest majority at 22.5%. Women comprised only 15.9% of the EiC positions (90% White and 10% Asian). Women were about half as likely to be in the EiC position compared with men [pOR 0.47 (95% CI, 0.23-0.95, P = .03)]. Women represented 28.3% of SiC editorial positions. Surgical oncology had the lowest female representation at 2.3%.

CONCLUSION

Women and minorities are significantly underrepresented in leadership roles on Editorial Boards in hematology/oncology journals. Importantly, the representation of minority women physicians in EiC positions is at an inexorable zero.

Analysis of Racial and Gender Distribution of US-Doctor of Medicines Graduates Entering Into General Surgery and Surgical Subspecialties' Residencies: The Need for Effective & Sustainable Diversity, Equity, and Inclusion Strategies

INTRODUCTION

We aim to investigate disparities & inequities based on race, sex, graduating age, and the number of peer-reviewed publications among allopathic U.S. Doctor of Medicine graduates who reported entering a surgical training program over a span of 5 y.

METHODS

A retrospective cohort analysis of the Association of American Medical Colleges student records system and Electronic Residency Application Service for graduates entering a surgical specialty residency during graduate medical education training cycles 2015-2020.

RESULTS

African American, Asian, and Hispanic applicants each accounted for less than 1% of graduates who reported entering a surgical training program. Asians (OR = 0.58, P = 0.01) and those identifying as other races (OR = 0.74, P = 0.01) were significantly less likely to enter a surgical subspecialty when compared to Caucasians. Orthopedic surgery contained the lowest proportion of minorities; African Americans 0.5% (n = 18), Asians 0.3% (n = 11), Hispanics 0.1% (n = 4), and others with 2% (n = 68). Females who reported entering Orthopedic surgery training represented the smallest female population in surgical specialties (17%, n = 527). The number of peer-reviewed publications was significantly associated with male sex (β = 0.28, P < 0.01), age between 30 and 32 at graduation (β = 1.76, P < 0.01), and identification as other races (β = 1.53, P < 0.01).

CONCLUSIONS

Racial minorities represented only 5.1% of graduates who reported entering a surgical specialty graduate medical education training program. Minority races and females were significantly less likely to enter a surgical subspecialty training program compared to Caucasian graduates and males, especially in orthopedic surgery. Implementation of specialty-specific programs and diversity, equity, and inclusion departments that promote mentorship and guidance toward residency programs is needed to combat continued race and sex disparities.

The Current State of Workforce Diversity and Inclusion in Pediatric Critical Care

Literature suggests the pediatric critical care (PCC) workforce includes limited providers from groups underrepresented in medicine (URiM; African American/Black, Hispanic/Latinx, American Indian/Alaska Native, Native Hawaiian/Pacific Islander). Additionally, women and providers URiM hold fewer leadership positions regardless of health-care discipline or specialty. Data on sexual and gender minority representation and persons with different physical abilities within the PCC workforce are incomplete or unknown. More data are needed to understand the true landscape of the PCC workforce across disciplines. Efforts to increase representation, promote mentorship/sponsorship, and cultivate inclusivity must be prioritized to foster diversity and inclusion in PCC.

Career Satisfaction and Burnout among American Muslim Physicians

Background  Career satisfaction and burnout among physicians are important to study because they impact healthcare quality, outcomes, and physicians' well-being. Relationships between religiosity and these constructs are underexplored, and Muslim American physicians are an understudied population. Methods  To explore relationships between career satisfaction, burnout, and callousness and Muslim physician characteristics, a questionnaire including measures of religiosity, career satisfaction, burnout, callousness, and sociodemographic characteristics was mailed to a random sample of Islamic Medical Association of North America members. Statistical relationships were explored using chi-squared tests and logistic regression models. Results  There were 255 respondents (41% response rate) with a mean age of 52 years. Most (70%) were male, South Asian (70%), and immigrated to the United States as adults (65%). Nearly all (89%) considered Islam the most or very important part of their life, and 85% reported being somewhat or very satisfied with their career. Multivariate models revealed that workplace accommodation of religious identity is the strongest predictor of career satisfaction (odds ratio [OR]: 2.69, p  = 0.015) and that respondents who considered religious practice to be the most important part of their lives had higher odds of being satisfied with their career (OR: 2.21, p  = 0.049) and lower odds of burnout (OR: 0.51, p  = 0.016). Participants who felt that their religion negatively influenced their relationships with colleagues had higher odds of callousness (OR: 2.25, p  = 0.003). Conclusions  For Muslim physicians, holding their religion to be the most important part of their life positively associates with career satisfaction and lower odds of burnout and callousness. Critically, perceptions that one's workplace accommodates a physician's religious identity associate strongly with career satisfaction. In this era of attention to physician well-being, the importance of religiosity and religious identity accommodations to positive career outcomes deserves focused policy attention.

Barriers in applying to genetic counseling Master's degree programs: Perceptions of prospective applicants when compared with Canadian admissions committee members

The goal of this study was to identify potential barriers in applying to a genetic counseling (GC) Master's degree program to inform strategies for increasing diversity and inclusiveness in the GC student recruitment process. Participants included prospective GC program applicants and admissions committee members from the four Canadian accredited programs. The study was conducted using a quantitative survey-based approach. Twenty-five prospective applicants who previously applied to a GC Master's degree program, 26 who had not applied, and 48 admissions committee members completed the survey. The small number of positions in GC programs was perceived by all groups as highly likely to impact an applicant's ability to gain acceptance to a program as was the limited number of GC training programs. Prospective applicants perceived additional barriers as significantly more likely to impact an individual's ability to apply to/attend a program when compared with admissions committee members including: cost of the application process, the applicant being a visible minority and the applicant having a physical disability. These findings highlight a number of perceived barriers related to applying to a GC Master's degree program. To our knowledge, this is the first study surveying prospective applicants and admissions committee members on barriers faced during the application process. The data from this study can also be used to inform the application process for other health professions.

Health occupations salary outcomes: intersections of student race, gender, and first-generation status

Greater diversity in the healthcare workforce has been identified as a critical need in serving an increasingly diverse population. Higher education institutions have been tasked with increasing the number of underrepresented students in the health occupations pipeline to better align with the demographics of the general population and meet the need for a diverse health occupations workforce. This study used the National Science Foundation's National Survey of College Graduates dataset to capture data across time, examining the intersectionality of race, gender, and first-generation status on the salary outcomes of students who earn degrees related to health occupations. Results indicate that the intersecting identities of students who earn a bachelor's degree or higher in the health professions impact salary outcomes. Results of this study have implications for higher education policies that can impact increased diversity in the health occupations workforce pipeline.

Flexible, short-duration outreach sessions in the human anatomy laboratory provide authentic, humanistic experiences

Anatomy laboratories can provide rich opportunities for outreach to K-12 and college students interested in pursuing careers in health, medicine, or science. At the University of Missouri, the Department of Pathology and Anatomical Sciences has designed flexible, one-hour interactive sessions that typically cover basic anatomical concepts using whole-body donors. In order to evaluate whether short-duration programs were impactful in increasing enthusiasm for anatomy and the health professions sciences, we used mixed methods to study participant experience covering three topics: (1) enthusiasm for anatomy, (2) interest in pursuing a career in healthcare professions, and (3) perception of the importance of whole-body donation. The same questions were asked pre- and post-session, and the post-session survey had additional questions related to student satisfaction. Quantitative analyses showed an increased interest in anatomy and appreciation for whole-body donation following the session. Students also perceived that they had a better understanding of the body and what it would be like to attend a health professions school. Thematic analysis revealed an appreciation for contextualizing the size, position, and hands-on feel of anatomical structures, and emphasized that students felt that they understood the body better after having seen a donor's anatomy. This work shows that short-duration, flexible outreach sessions involving whole-body donors can provide students with a rare opportunity to confirm their contextual understanding of anatomy, and provide students with an authentic, and humanistic experience.

Active Bystander Training: Using Standardized Patient Methodology to Teach Residents to Navigate Microaggressions in Patient Encounters

Introduction

Studies show that physicians and medical trainees who identify as underrepresented in medicine or as women experience higher rates of microaggressions during patient encounters. We designed, implemented, and evaluated an active bystander training workshop focused on mitigating microaggressions using standardized patient (SP) methodology.

Methods

Internal medicine faculty members and chief residents led the workshop. Participants included 31 PGY 1 categorical and preliminary internal medicine residents. They participated in three case simulations with SPs involving microaggressions from patients toward a member of the health care team. Prior to the case simulations, a brief presentation outlined examples of microaggressions and reviewed the behavioral response framework WAKE (work with who you are, ask questions/make direct statements, involve key people, and employ distraction techniques). After each encounter, residents debriefed with an internal medicine faculty member and discussed questions related to each scenario.

Results

All 31 residents participated in the workshop and, before and after the activity, completed a survey that asked them to rank their agreement with statements via a Likert scale. Participants reported statistically significant improvement in recognizing microaggressions (12% reported increase, p = .002), the ability to respond to patients who exhibit microaggressions (23% reported increase, p < .001), and the ability to debrief with team members (20% reported increase, p < .001).

Discussion

SP simulations can be an effective teaching modality for microaggression response strategies during patient encounters. Additional studies are needed to further characterize the workshop's effect on other medical workforce trainees and retention of skills over time.

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.

Diversity and demographics of APSA members: Understanding our identity

INTRODUCTION

There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care.

METHODS

1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests.

RESULTS

Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools.

CONCLUSION

There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential.

TYPE OF STUDY

Survey; original research.

LEVEL OF EVIDENCE

Level IV.

Neural Impacts of Stigma, Racism, and Discrimination

Racism is a chronic stressor fueled by stigma that can result in significant distress and dysfunction as well as negatively affect emotions, behavior, quality of life, and brain health. The effects of stigma and discrimination emerge early in life and have long-term consequences. In this review, we sought to use neuroscience research to describe how stigma, racism, and discrimination can impact brain and mental health. Societal stigmas may be encoded by associative fear learning and pattern completion networks, and experiences of racial discrimination may similarly affect threat-responsive regions and circuits. Race-related differences in brain function and structure supporting threat circuitry are largely attenuated when negative life experiences and discrimination are taken into account. Downstream, chronic activation of the hypothalamic-pituitary-adrenal axis and the sympathetic-adrenal-medullary axis in the context of discrimination and stigma can contribute to physical health disparities in minoritized and marginalized groups. Finally, we discuss models that provide a framework for interventions and societal-level strategies across ecologic systems to build resilience and foster posttraumatic growth.

Institutional Variability in Representation of Women and Racial and Ethnic Minority Groups Among Medical School Faculty

IMPORTANCE

Bolstering the ranks of women and underrepresented groups in medicine (URM) among medical faculty can help address ongoing health care disparities and therefore constitutes a critical public health need. There are increasing proportions of URM faculty, but comparisons of these changes with shifts in regional populations are lacking.

OBJECTIVE

To quantify the representation of women and URM and assess changes and variability in representation by individual US medical schools.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study assessed US medical school faculty rosters for women and URM, including American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian or other Pacific Islander faculty. US allopathic medical schools participating in the Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System from 1990 to 2019 (updated December 31 for each year), were included. Faculty data were analyzed from yearly cross-sections updated as of December 31 for each year from 1990 to 2019. For census data, decennial census data were used for years 1990, 2000, and 2010. Intercensal estimates were used for all other years from 1990 to 2019.

MAIN OUTCOMES AND MEASURES

Trends and variability in representation quotient (RQ), defined as representation of a group within an institution's faculty compared to its respective US county.

RESULTS

There were 121 AAMC member institutions (72 076 faculty) in 1990, which increased to 144 institutions (184 577 faculty) in 2019. The median RQ of women faculty increased from 0.42 (IQR, 0.37-0.46) to 0.80 (IQR, 0.74-0.89) (slope, +1.4% per year; P < .001). The median RQ of Black faculty increased from 0.10 (IQR, 0.06-0.22) to 0.22 (IQR, 0.14-0.41) (slope, +0.5% per year; P < .001), but remained low. In contrast, the median RQ of Hispanic faculty decreased from 0.44 (IQR, 0.19-1.22) to 0.34 (IQR, 0.23-0.62) (slope, -1.7% per year; P < .001) between 1990 and 2019. Absolute total change in RQ of URM showed an increase; however, the 30-year slope did not differ from zero (+0.1% per year; P = .052). Although RQ of women faculty increased for most institutions (127 [88.2%]), large variability in URM faculty trends were observed (57 institutions [39.6%] with increased RQ and 10 institutions [6.9%] with decreased RQ). Nearly one-quarter of institutions shifted from the top to bottom 50th percentile institutional ranking by URM RQ with county vs national comparisons.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that representation of women in academic medicine improved with time, while URM overall experienced only modest increases with wide variability across institutions. Among URM, the Hispanic population has lost representational ground. County-based population comparisons provide new insights into institutional variation in representation among medical school faculty.

Impacts of a Clinical Research Program for High School Students from Groups Historically Excluded from Science and Medicine

Introduction

Pathway programs engage students who identify with groups historically excluded from, and therefore underrepresented in, science, technology, engineering, math, and medicine (STEMM). We explored alumni-reported impacts of eight U.S. high school-to-college pathway programs funded by the Doris Duke Charitable Foundation (DDCF).

Methods

A survey was sent to 499 alumni to evaluate their perceptions of the DDCF programs, which offer mentored experiences in clinical research. A multivariate analysis was used to compare Likert-style questions related to the programs' impact on education and career plans. Open-ended responses were analyzed using inductive analysis.

Results

Two hundred sixty-nine alumni responded to the survey, the majority of whom identified as Hispanic/Latinx or Black/African American. One hundred nineteen alumni (∼75%) currently in college reported majoring in STEMM fields. Of college graduates, 30 (∼65%) obtained a degree in an STEMM field. Participants identifying as Hispanic/Latinx had a significantly higher reported level of impact of the programs on their plans to attend college. Most alumni felt that the programs impacted their chosen majors and future professions and made them more confident to pursue careers in STEMM.

Discussion

Surveyed alumni perceive DDCF programs to have positively impacted their interest, confidence, and skills in STEMM-related areas. Our results support the benefit of DDCF programs and substantiate their funding, integration into higher education systems, and iterative redesign to ensure positive impacts on students with diverse backgrounds.

Health Equity Implications

Assessment and improvement of pathway programs may support underrepresented students in their STEMM aspirations and increase the diversity of the medical and scientific workforce.

Recommendations to improve recruitment and retention of underrepresented in medicine trainees in neonatal-perinatal medicine

Physicians who identify as Black, Latinx, American Indian, Pacific Islander, and certain Asian subgroups represent racial and ethnic populations that are underrepresented in medicine (URM). While the proportion of URM pediatric trainees has remained unchanged, that of Neonatal-Perinatal Medicine (NPM) fellows has decreased. Informed by the medical literature and our lived experiences, we compiled and developed a list of recommendations to support NPM fellowship programs in the recruitment, retention, and promotion of URM trainees. We describe ten recommendations that address 1) creating a culture of inclusivity and psychological safety, 2) the critical appraisal of recruitment practices and climate, and 3) an inclusive and holistic fellowship application process. The first two themes lay the foundation, while the final theme spotlights our recommendations for URM recruitment. Each recommendation is a step towards improvement in recruitment and inclusion at a program.

Integrated Holistic Student Affairs: A Personalized, Equitable, Student-Centered Approach to Student Affairs

Medical education has reached a critical juncture-the structural racism that has permeated the fabric of its systems and institutions for centuries can no longer be ignored. The destructive, disproportionate impact of the COVID-19 pandemic and unabated violence targeting individuals who are Black, Indigenous, and People of Color (BIPOC) exact an incalculable toll on BIPOC students and students from other groups that are historically underrepresented in medicine (UIM). Failing to recognize and act on the well-documented differential experience of BIPOC medical students impedes medical educators' ability to cultivate learning environments where all learners have an equitable opportunity to thrive. Holistic review admission processes, now widely accepted, have challenged admissions committees to consider the "whole applicant" to diversify matriculating classes. While gaining admission is critical, it is merely the first step for BIPOC students, who may face marginalization within what the authors have termed a "sink-or-swim" culture in medical education. For the tremendous potential afforded by holistic review to be realized, the medical education community must extend the holistic approach throughout the medical education continuum, beginning with student affairs practices and support. The authors propose the use of Integrated Holistic Student Affairs (IHSA), a systems-based model that fosters the reexamining and reengineering of existing student affairs structures, policies, and processes to promote a personalized, equitable student-centered approach. The IHSA Model consists of 4 strategic actions-establish vertical and horizontal collaboration, conduct systems thinking analysis, target leverage points for change, and operationalize the change process-and 4 areas of priority for collaboration with student diversity affairs staff and faculty. The IHSA Model provides student affairs staff and faculty with a framework for shifting from reactive, deficit-oriented practices to proactive, empowering, equitable practices, with the goal of allowing BIPOC and all other UIM students to thrive during their journey from matriculation to graduation.

The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity

IMPORTANCE

Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.

OBJECTIVE

To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.

EVIDENCE REVIEW

Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.

FINDINGS

Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.

CONCLUSIONS AND RELEVANCE

Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Addressing Health Equity and Racism Through a Hispanic Psychiatry Fellowship

The scarcity of bilingual psychiatrists, as well as appropriate mental health services for populations with limited English proficiency, has led to inequitable health outcomes. A fellowship program was developed, which draws from a clinical model staffed by bilingual (Spanish-English) professionals from racial-ethnic minority groups, to address access to care and the structural determinants of health. This new Hispanic Psychiatry Fellowship focuses on health inequality and racism in policy and leadership, clinical care for Spanish-speaking patients, cultural psychiatry, recovery, forensics, substance use, and education. This column describes the program's development, first 2 years of implementation, and feasibility indicators for use in creating similar programs.

Diversity in Radiology: Current Status and Trends Over the Past Decade

Background There have been growing efforts nationally and institutionally toward diversity in radiology. Purpose To analyze sex and racial and ethnic diversity over time (2010-2019) for the various levels of the U.S. academic radiology physician workforce in context of the available pipeline of medical students and trainees. Materials and Methods Data on sex and race and ethnicity were collected among medical school applicants, graduates, radiology residency applicants, residents, and different levels of academic radiology faculty. All trainee data were obtained from two time points, 2010-2011 and 2019-2020. Radiology faculty data were collected from 2010 to 2019. The sex and racial and ethnic composition at each academic level was compared between 2010 and 2019 using the χ² test and a significance level of P < .05. Results In 2019, the percentage of female faculty among radiology instructors was 38% (251 of 655); assistant professors, 31% (1503 of 4801); associate professors, 28% (600 of 2161); professors, 22% (424 of 1901); and department chairs, 17% (37 of 220). The proportion of female faculty increased from 2010 to 2019, with the greatest relative increase in percentages among the more senior faculty positions. However, the proportion of female department chairs has only increased from 13% (27 of 203) in 2010 to 17% (37 of 220) in 2019. Across training levels, the most abrupt change in composition of female trainees occurred from medical school matriculates (52%, 11 160 of 21 614) to radiology residency applicants (29%, 656 of 2274), which largely stayed unchanged from 2010 to 2019. The proportion of Black or African American department chairs was 5% (10 of 220) in 2019, which was higher compared with that of assistant professor, associate professor, and professor levels for Black or African American faculty (3% [130 of 4949], 2% [41 of 2208], and 2% [35 of 1924], respectively), with proportions of Hispanic faculty at 5% (240 of 4949), 4% (96 of 2208), and 3% (60 of 1924), respectively. These proportions have not changed since 2010. Conclusion Identifying and addressing reasons for the low proportion of female radiology residency applicants despite a highly diverse pool of medical students would be key to increasing female representation in the field. The low representation of African American and Hispanic individuals in academic radiology is seen at all levels and has not changed much over time. Efforts to increase diversity may need to be focused toward the medical school and residency application levels. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Pandharipande and Shah in this issue.

Race reporting and disparities regarding clinical trials in bladder cancer: a systematic review

PURPOSE

To systematically review the literature to investigate racial disparities among bladder cancer clinical trial enrollees.

METHODS

A systematic review was conducted using Ovid, MEDLINE® to identify clinical trials between 1970 and 2020. Articles were reviewed and were included if they assessed race in their outcomes reporting among bladder cancer patients enrolled in clinical trials. The review was conducted in accordance with the PRISMA statement.

RESULTS

We identified 544 clinical trials meeting our initial search criteria, with only 24 (4.4%) studies reporting racial demographic data. Enrollees were largely Caucasian (81-98%), with a strikingly small proportion of enrolled patients consisting of African-Americans (2-8%) and Hispanics (2-5%). Only one of the studies reported results on the efficacy and safety/tolerability of the tested treatment separately for racial groups and performed analyses stratified by race.

CONCLUSION

Race is poorly studied in bladder cancer clinical trials. Trial cohorts may not reflect multicultural populations. The potential association between race and efficacy, safety or tolerability of the tested interventions is unknown. Given the up to twofold increase in bladder cancer-specific death among African-Americans, further research is needed to address the impact of race in clinical trials, while encompassing socioeconomic factors and disease risk factor exposures.

Gender profile of principal investigators in a large academic clinical trials group

Introduction

Gender equity in medicine has become a significant topic of discussion due to consistently low female representation in academia and leadership roles. Gender imbalance directly affects patient care. This study examined the gender and craft group of the Principal Investigators (PI) of clinical trials run by the Australasian Gastro-Intestinal Trials Group (AGITG)

Methods

Publicly available data was obtained from the AGITG website. Trials were divided into upper, lower gastrointestinal cancer, miscellaneous (neuroendocrine and gastrointestinal stromal tumours). Where multiple PIs were listed, all were counted. Craft group was assigned as surgical, medical, radiation oncology or other.

Results

There were 69 trials with 89 PI, where 52 trials were represented exclusively by male PIs. Of all PIs, 18 were women (20.2%); all were medical oncologists. Prior to 2005, all PIs were male. The craft group distribution of PIs was: 79% medical oncologists, 12% surgical oncologists, 8% radiation oncologist, 1% nuclear medicine physicians. Regarding trials with multiple PI's, there were 19 in total. Of these, 11 had only male PIs, which included 5 surgeons. Females were more likely to be a co-PI (42%) as opposed to sole PI (18%). There was no gender policy publicly available on the AGITG website.

Conclusions

There is a low percentage of female PIs in academic oncology trials in the portfolio of this large international trials group. No trial was led by a female surgical or radiation oncologist. There is a need to understand the reasons driving the disparity so that specific strategies can be put in place.