Current and Historical Trends in Diversity by Race, Ethnicity, and Sex Within the US Pathology Physician Workforce

Racial and Ethnic Discrimination and Medical Students' Identity Formation

Importance

Investigating racial and ethnic discrimination in medical education is crucial for addressing disparities and fostering an inclusive environment.

Objective

To assess how racial and ethnic discrimination in medical school is associated with personal and professional identity formation (PPIF) by race and ethnicity.

Design, Setting, and Participants

This retrospective cross-sectional study used deidentified data on 37 610 medical students who matriculated in 2014 or 2015 and took the Association of American Medical Colleges Graduation Questionnaire (GQ) between 2016 and 2020. Statistical analysis was performed from September 1 to November 20, 2023.

Exposures

Experiences of racial and ethnic discrimination were assessed through responses to 3 GQ questions about denial of opportunities, offensive remarks or names, and lower evaluations or grades due to race or ethnicity.

Main Outcomes and Measures

Personal and professional development were measured as 2 separate outcomes using 2 GQ statements rated on a 5-point Likert scale (where 1 indicated strongly disagree and 5 indicated strongly agree): "My medical school has done a good job fostering and nurturing my development as a person" and "My medical school has done a good job fostering and nurturing my development as a physician." Variables of personal and professional development were both dichotomized.

Results

Of 37 610 medical students, 18 200 (48.4%) were female, and 19 410 (51.6%) were male; 2458 (6.5%) were African American or Black, 7801 (20.7%) were Asian, 2430 (6.5%) were Hispanic, 21 380 (56.9%) were White, 2404 (6.4%) were multiracial, and 1137 (3%) were other race or ethnicity. Most respondents attested that their medical school fostered their personal (27 272 [72.5%]) and professional (34 560 [91.9%]) development. African American or Black students reported the lowest rates of personal (1603 of 2458 [65.2%]) and professional (2182 of 2458 [88.8%]) development, and experienced lower likelihoods of personal (adjusted risk ratio [ARR], 0.89 [95% CI, 0.86-0.93]) and professional (ARR, 0.95 [95% CI, 0.94-0.97]) development than White students. Racial discrimination was inversely associated with development, with the highest PPIF rates among those never experiencing discrimination (personal, 25 089 of 33 508 [74.9%]; and professional, 31 257 of 33 508 [93.3%]). Those experiencing isolated discrimination (personal: ARR, 0.83 [95% CI, 0.80-0.87]; professional: ARR, 0.92 [95% CI, 0.91-0.95]) and recurrent discrimination (personal: ARR, 0.63 [95% CI, 0.60-0.66]; professional: ARR, 0.82 [95% CI, 0.80-0.84]) had relatively lower likelihoods of PPIF. African American or Black students experienced the highest rate of recurrent discrimination (543 of 2458 [22.1%]). No significant PPIF risk differences were found for other racial and ethnic groups underrepresented in medicine without discrimination compared with White students without discrimination, but all groups with recurrent discrimination had relatively lower PPIF risk.

Conclusions and Relevance

In this cross-sectional study of US medical students, racial and ethnic discrimination was associated with lower PPIF across all racial and ethnic groups compared with White students without such experiences. African American or Black students disproportionately faced this discrimination. Systemic changes in medical education are needed to combat discrimination and ensure equity in holistic student development.

Is Social Media Here to Stay?: Survey Results Indicate Increasing Pathologist Interest and Engagement Over Time

CONTEXT.—

Social media has become widely adopted by pathologists and other physicians for professional purposes. While engagement has likely increased over time, there remain few concrete data regarding attitudes toward its use.

OBJECTIVE.—

To assess pathologists' use of and attitudes toward social media over time.

DESIGN.—

We created a survey regarding personal and professional use of social media and circulated it via multiple channels in December 2017 and again in February 2022. Results of the 2 surveys were compared for statistically significant differences.

RESULTS.—

The 2017 survey was completed by 97 participants, and the 2022 survey by 305 participants. Respondents were predominantly female and academics, included pathologists in all age categories and all time-in-practice length. In both surveys, Twitter (now X) was the most popular platform for professional use and Facebook was the most popular for personal use. Professional barriers to social media use remained consistent between the 2 surveys, including the amount of time required. Education was seen as the main benefit of social media use in both surveys, while other benefits such as networking and increasing professional visibility were endorsed significantly less often in the second survey. While the second survey received more than 3 times as many responses as the first, several aspects of social media use (mainly demographics) remained similar during the timeframe, while other aspects (such as usage and perceived values) decreased.

CONCLUSIONS.—

Pathologists continue to find social media valuable. Barriers remain, though overall pathologists of all ages and practice settings appear receptive to using social media to further educational and other opportunities.

Cytopathology fellowship and practice: Are our trainees and cytopathologists diverse?

Over the last several years, there has been increased focus on diversity, equity, and inclusion within all areas of pathology and laboratory medicine. Many of the specialty societies within pathology have taken up the mantle of diversity. While there is little research into the diversity of cytopathologists in practice, the Accreditation Council for Graduate Medical Education (ACGME) has been collecting diversity data on pathology and laboratory medicine trainees since 2011. This data are an opportunity to explore how diverse our trainees in cytopathology are, and by extrapolation, allows us to develop some ideas as to how diverse attending level cytopathologists are. The author will also share personal observations from her own training and career regarding diversity in cytopathology.

Science, Medicine, and Cytology: an educational program of the Diversity, Equity, and Inclusion Committee of the American Society of Cytopathology

INTRODUCTION

As our field of pathology continues to grow, our trainee numbers are on the decline. To combat this trend, the ASC Diversity, Equity, and Inclusion Committee established the Science, Medicine, and Cytology SumMer Certificate program to improve exposure to pathology/cytopathology with a focus on diversity, equity, and inclusion. Herein, we report our findings of the first 2 years of the program.

MATERIALS AND METHODS

An online course was developed targeting students who are underrepresented in medicine at the high school and college level. It consisted of several didactic sessions, presenting the common procedures involving cytopathologists and cytologists. Interviews with cytopathologists were also included. Participants were surveyed for demographic information and provided course evaluations.

RESULTS

In the first year of the program (2021), 34 participants completed the program, which increased to 103 in 2022. In both years there was a diversity in participant demographic backgrounds; however, only a minority of participants self-identified as being underrepresented in medicine. A vast majority (>85%) of participants in both years were high school or college students. In 2021, 100% of participants stated that the program format was effective and 94% thought the content was appropriate for their level of education; in 2022 the results were similar. In 2021, 66% considered health care as a potential career; this value increased in 2022 to 83%. In 2021 and 2022, 31% and 38%, respectively, considered cytology as a career.

CONCLUSIONS

Evaluations were excellent, generating interest in cytopathology. Barriers in reaching underrepresented minorities exist and additional work is needed. Expansion to a wider audience may increase outreach.

The physician experience of patient to provider prejudice (PPtP)

Background

Patients can demonstrate prejudice and bias toward minoritized physicians in a destructive dynamic identified as PPtP (Patient Prejudice toward Providers). These interactions have a negative impact on the physical and mental well-being of both those who are targeted and those who witness such behaviors.

Study purpose

The purpose of this study was to explore the PPtP experiences of attending physicians who identify as a minority based on race, ethnicity, citizenship status, or faith preference.

Methods

Qualitative methodology was used to collect data using in-depth interviews. 15 attending physicians (8 male, 7 female, aged 33-55 years) who identified as minorities based on ethnicity, citizenship status, or faith practices were interviewed individually. Interviews were conducted using a guide validated in previous studies and content analysis was performed by two trained researchers to identify themes.

Results

Five themes were identified: A Continuum of Offenses, Professional Growth through Adversity, Organizational Issues, Role of Colleagues, and Consequences for Provision of Care. Findings suggest that although attending physicians learned to cope with PPtP, the experience of being treated with bias negatively impacted their well-being and work performance. Attending physicians also felt that white majority medical students sometimes treated them with prejudice but expressed a commitment to protecting vulnerable trainees from PPtP.

Conclusion

The experience of PPtP occurs consistently throughout a career in medicine, often beginning in the years of training and persisting into the phase of attending status. This makes it imperative to include strategies that address PPtP in order to successfully recruit and retain minoritized physicians.

German Physicians and Medical Students Do Not Represent the Population They Serve

Medical professionals who represent the communities they serve are in a better position to understand patients' social circumstances and communicate in a more patient-centered way. International studies show limited diversity and underrepresentation of certain social groups in the population of physicians and medical students. We designed an observational study to investigate the cultural and socio-economic diversity of physicians and medical applicants in comparison to the general population in Germany. We invited 15,195 physicians in Hamburg and 11,287 medical applicants in Germany to participate in an online survey between June and August 2022. The lower three quintiles of objective socio-economic background (SEB) were vastly underrepresented in all subsamples of the study and in particular amongst applicants and students admitted in Hamburg: 57.9% of physicians and 73.8% of medical students in Hamburg originate from the top quintile of SEB. The Turkish and Polish communities were particularly underrepresented in the group of physicians from Hamburg and medical applicants and students in Germany (p = 0.02; p < 0.001). In line with existing evidence, the vast majority of physicians and medical students come from the most affluent households when entering medical school. Widening participation strategies are needed to facilitate fairer access to the study of medicine in Germany.

Demographics and perceptions of diversity in dermatopathology workforce and training environments in the United States

OBJECTIVES

The aim of this study was to determine the demographics and perceptions of diversity, equity, and inclusion (DEI) in the field of dermatopathology to provide a measurable baseline for future efforts to enhance equity measures within our subspecialty.

METHODS

A questionnaire based on a previously validated instrument by Association of American Medical Colleges (AAMC) was sent to American Society of Dermatopathology (ASDP) members to collect the demographic information (gender, race, sexual orientation, disability, experience and practice setting, etc.) and evaluate eight diversity, engagement, and inclusivity statements on a 1-5 Likert scale.

RESULTS

The demographics of 207 of 1331 (15%) respondents showed slight male predominance. Eleven percent of respondents identified as LGBTQI. The major racial distribution was comprised of 62% White, 18% Asian (including Middle Eastern/Indian), 10% Hispanic, and 4% Black respondents. New-in-practice respondents (those in practice-5 years or less) were more likely to have a pathology background (71% vs. 56%, p = 0.047) than their more-established peers with more than 5 years of service. This trend also contributed to increased diversity in terms of gender (66% females) and race (48% non-White) among the newer generation. Dermatology-trained dermatopathologists were mostly White (70%) and male (53%). Analysis of respondent demographics with perception statements showed that White and US graduate respondents (compared to other groups) were more likely to have a positive perception about DEI within the field of dermatopathology.

CONCLUSIONS

The results provide a snapshot of the current state of diversity within the field of dermatopathology. Moreover, these results highlight opportunities for further increasing diversity in general and leadership in particular within dermatopathology.

Analysis of Industry-Related Payments Among Physician Editors of Pathology Journals

OBJECTIVES

Gender inequities in editorial board representation and physician compensation are well documented, but few studies have focused on how editors of journals are compensated.

METHODS

In this cross-sectional study, we examined industry-related compensation (from 2014 to 2020) among physician editors of 35 pathology journals using publicly available data from the Centers for Medicare & Medicaid Services Open Payments Database.

RESULTS

Of the physician editors included, 135 (69.9%) were men and 58 (30.1%) were women. Similar percentages of men and women physicians who were eligible received payments (112/135 [83.0%] men and 51/58 [87.9%] women; P = .38, χ2 test). Of the total transfer of value ($211,192,532), 112 men received $192,727,555 (91.3%), and 51 women received $18,464,978 (8.7%). Mean total payment per person was $1,720,782 for men and $362,058 for women (P = .05). The payment range for men was $18-$47,568,400 and the range of payments for women was $31-$2,375,637.

CONCLUSIONS

The findings highlight significant gender inequities in industry-related payments to physician editors of pathology journals. The financial relationships of journal editors and industry deserve further study, particularly as they relate to advancing science and closing both workforce and patient care inequities.

Optimizing Equity: Working towards Fair Machine Learning Algorithms in Laboratory Medicine

BACKGROUND

Methods of machine learning provide opportunities to use real-world data to solve complex problems. Applications of these methods in laboratory medicine promise to increase diagnostic accuracy and streamline laboratory operations leading to improvement in the quality and efficiency of healthcare delivery. However, machine learning models are vulnerable to learning from undesirable patterns in the data that reflect societal biases. As a result, irresponsible application of machine learning may lead to the perpetuation, or even amplification, of existing disparities in healthcare outcomes.

CONTENT

In this work, we review what it means for a model to be unfair, discuss the various ways that machine learning models become unfair, and present engineering principles emerging from the field of algorithmic fairness. These materials are presented with a focus on the development of machine learning models in laboratory medicine.

SUMMARY

We hope that this work will serve to increase awareness, and stimulate further discussion, of this important issue among laboratorians as the field moves forward with the incorporation of machine learning models into laboratory practice.

Gender distribution of editors and authors of reference textbooks in anatomic pathology: further edits are required

Compared to other medical specialties, pathology has a significant number of women in the academic workforce (43%). Gender disparities, particularly those disadvantaging women, are a reality in academic medicine with documented inequalities in salary, leadership opportunities, and faculty promotion. One important element of academic advancement is the recognition obtained when serving as editor or main author of reference textbooks. We aimed to document the gender distribution of editors/authors in anatomic pathology by surveying 205 subspecialty publications over a 20-year period. Gender of each editor/author was recorded after surveying their institutional or other professional biographies. When biography was non-contributory, gender was extracted from the National Provider Identifier Database. A total of 462 editors/authors were identified: 275 (59.5%) men and 187 (40.5%) women. This distribution was similar to the 2015 (39% women) and 2019 (43.4% women) Association of American Medical Colleges (AAMC) benchmark for US academic pathologists. The gender distribution in each of the main anatomic pathology subspecialties was estimated by surveying the websites of 20 North American academic pathology departments (totaling 1893 listed individuals). Compared to this benchmark, some subspecialties had more men in editor/author roles than their representation in academic departments including Dermatopathology (observed vs expected difference, ∆ = 41.3%), Genitourinary Pathology (∆ = 29.4%), Renal & Transplant Pathology (∆ = 22.4%) and Head & Neck Pathology (∆ = 21.6%). Other subspecialties had more women in editor/author roles than their representation in academic departments including Molecular Pathology (∆ = 31.4%), Gastrointestinal Pathology (∆ = 21.4%), and Bone & Soft Tissue Pathology (∆ = 19.4%). Editors/authors of multiple (>1) publications were frequent and skewed gender representation in most specialties. The overall gender distribution of editor/author roles is similar to that of the US pathology workforce. However, significant disparities exist in certain subspecialties affecting both women and men. This landscape can guide efforts by editors, publishers, and academic institutions to bring equity to the academic field by providing fair editorial and authorship opportunities to academic pathologists.

Diversity in forensic sciences: Black, Indigenous, and People of Color (BIPOC) representation in different medicolegal fields in the United States

The benefits of a diverse and inclusive working environment are well documented. This study examined forensic science literature, demographic data reported from professional organizations, and demographic surveys to compile information regarding racial and ethnic diversity within different subdisciplines of forensic science. Results showed that practitioners self-identified as Black or Hispanic were underrepresented in scientific fields closely related to forensic science. Moreover, Black, Indigenous, and People of Color (BIPOC) students were underrepresented at the undergraduate level, despite increasing college enrollments. This lack of representation may have consequences on knowledge production and innovation. By recognizing the current status of diversity in forensic science, this study is the first step toward mitigating the trend of underrepresentation. We encourage professional organizations to be transparent about the diversity in their membership and provide actual practitioner demographic statistics. These data are beneficial to studying the effects of underrepresentation and developing effective strategies to improve representation.

Recognition Awards in Pathology Specialty Societies

OBJECTIVES

Recognition awards build physician reputation and facilitate career advancement. We hypothesize women physicians are underrepresented as award recipients by pathology medical societies compared with representation in the specialty.

METHODS

We analyzed publicly available online information about physician recipients (January 2015 to December 2021) from three general pathology society websites. Recipient gender was determined by pronoun use, first name, and photograph. Representation was compared with Association of American Medical Colleges (AAMC) specialty data from 2015 and 2019, which showed a minimum of 36.7% women pathologists in 2015 and up to 43.4% in 2019.

RESULTS

Twenty-six awards and 230 physician recipients were included in the analysis. A total of 159 (69.1%) men physicians and 71 (30.9%) women physicians received awards. Overall, women physicians were underrepresented in recognition awards compared with AAMC benchmarks. Prestigious awards (defined as those that recognize a person's body of work over time) showed a similar disparity with 22 (30.1%) of 73 recipients being women. Men physicians were more likely to receive multiple awards.

CONCLUSIONS

Women physicians are underrepresented overall for recognition awards by pathology medical societies. Disparities are greater for prestigious awards. Further research is needed to better understand the reasons for these findings and how they affect women physicians' careers.

The medical student's guide to pathology residency, fellowships, and careers

Recent studies have shown that relatively few MD, DO, and underrepresented in medicine (URM) students and physicians are matching into pathology residency in the United States (US). In the 2021 Main Residency Match, just 33.6% of filled pathology residency positions were taken by senior year students at US allopathic medical schools. This has been attributed to the fact that pathology is not a required rotation in most US medical schools, pathology is often taught in an integrated curriculum in the US where is does not stand out as a distinct field, and because the COVID-19 pandemic led to a suspension of in-person pathology rotations and electives. Ultimately, many US medical students fail to consider pathology as a career pathway. The objective of this article is to provide medical students with basic information, in the form of frequently asked questions (FAQs), about pathology training and career opportunities. This was accomplished by forming a team of MD and DO pathology attendings, pathology trainees, and a medical student from multiple institutions to create a pathology guide for medical students. This guide includes information about post-sophomore fellowships, 5 major pathology residency tracks, more than 20 fellowship pathways, and allopathic and osteopathic board examinations. This guide also contains photographs and descriptions of major pathology sub-specialties, including the daily and on-call duties and responsibilities of pathology residents. The exciting future of pathology is also discussed. This guide supports the agenda of the College of American Pathologists' (CAP) Pathologist Pipeline Initiative to improve student recruitment into pathology.

Strategies to Enhance Diversity, Equity, and Inclusion in Pathology Training Programs: A Comprehensive Review of the Literature

CONTEXT.—

Like many medical specialties, pathology faces the ongoing challenge of effectively enriching diversity, equity, and inclusion within training programs and the field as a whole. This issue is furthered by a decline in US medical student interest in the field of pathology, possibly attributable to increasingly limited pathology exposure during medical school and medical student perceptions about careers in pathology.

OBJECTIVE.—

To review the literature to identify the challenges to diversity, equity, and inclusion in pathology, with an emphasis on the pathology trainee pipeline. To evaluate the medical education literature from other medical specialties for diversity and inclusion-focused studies and initiatives, and determine the outcomes and/or approaches relevant for pathology training programs.

DATA SOURCES.—

A literature review was completed by a search of the PubMed database, as well as a similar general Google search. Additional resources, including the Web sites of the Association of American Medical Colleges, the Electronic Residency Application Service, and the National Resident Matching Program, were used.

CONCLUSIONS.—

Many strategies exist to increase diversity and encourage an inclusive and equitable training environment, and many of these strategies may be applied to the field of pathology. Interventions such as increasing exposure to the field, using a holistic application review process, and addressing implicit biases have been shown to promote diversity, equity, and inclusion in many medical specialties. In addition, increasing access to elective and pipeline programs may help to bolster medical student interest in careers in pathology.