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Tremonti G, Shah NR, Moreci R, Hooper RC, Gadepalli SK, Newman EA. Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants. J Pediatr Surg 2024:S0022-3468(24)00302-6. [PMID: 38811257 DOI: 10.1016/j.jpedsurg.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/26/2024] [Accepted: 05/06/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Holistic review (HR) considers applicants' unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS). METHODS Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) [2015-2017] were compared to HR [2018-2022]. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate. RESULTS For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR. CONCLUSION Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Grace Tremonti
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nikhil R Shah
- Section of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Rebecca Moreci
- Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, MI, USA
| | - Rachel C Hooper
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Erika A Newman
- Section of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, USA.
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Cui CL, Loanzon RS, West-Livingston LN, Coleman DM, Long CA, Kim Y. The Diversity of Surgical Trainees Index identifies racial and ethnic disparities among surgical specialties. J Vasc Surg 2024:S0741-5214(24)00998-4. [PMID: 38631516 DOI: 10.1016/j.jvs.2024.03.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Racial and ethnic disparities have been well-described among surgical specialties; however, variations in underrepresented in medicine (URiM) representation between these specialties have not previously been quantified. METHODS Data collected from Accreditation Council for Graduate Medical Education (ACGME) annual reports were used to derive the Diversity of Surgical Trainee Index (DoSTI), which was calculated as the proportion of URiM residents and fellow physicians within a given surgical specialty, relative to the overall proportion of URiM trainees within all surgical and non-surgical ACGME-accredited programs in the same academic year. RESULTS From 2013 to 2022, a total of 108,193 ACGME-accredited residency programs trained 1,296,204 residents and fellows in the United States. Of these, 14.1% (n = 182,680) of trainees self-identified as URiM over the study period. The mean DoSTI among all surgical specialties was 0.80 (standard error, 0.01) compared with all ACGME-accredited programs. High DoSTI specialties incorporated significantly higher proportions of trainees who identify as Hispanic (8.7% vs 6.3%) and Black or African American (5.2% vs 2.5%) when compared with low DoSTI specialties (P < .0001 each). General surgery (1.06 ± 0.01), plastic surgery (traditional) (1.12 ± 0.06), vascular surgery (integrated) (0.96 ± 0.03), and vascular surgery (traditional) (0.94 ± 0.06) had the highest DoSTI (P < .05 each vs composite). On linear regression analysis, only ophthalmology (+0.01/year; R2 = 0.41; P = .019), orthopedic surgery (+0.01/year; R2 = 0.33; P = .047), otolaryngology (+0.02/year; R2 = 0.86; P < .001), and pediatric surgery (+0.06/year; R2 = 0.33; P = .048) demonstrated an annual increase in DoSTI. CONCLUSIONS The DoSTI is a novel metric used to quantify the degree of URiM representation among surgical specialties. DoSTI has revealed specialty-specific variations in racial/ethnic minority representation among surgical training programs. This metric may be used to improve provider awareness and identify high performing DoSTI specialties to highlight best practices to ultimately recruit a more diverse surgical workforce.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Roberto S Loanzon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Lauren N West-Livingston
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Dawn M Coleman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Nguyen M, Gonzalez L, Stain SC, Dardik A, Chaudhry SI, Desai MM, Boatright D, Butler PD. Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity With Sustained and Cultivated Careers in Surgery. Ann Surg 2024; 279:367-373. [PMID: 37470162 PMCID: PMC10799171 DOI: 10.1097/sla.0000000000006029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS This retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery [adjusted relative risk (aRR): 0.92 (0.85-0.98)], while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates. CONCLUSIONS AND RELEVANCE This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.
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Affiliation(s)
| | | | - Steven C Stain
- Department of Surgery, Lahey Hospital and Medical Center, Boston, MA
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
- Department of Surgery, VA Connecticut Healthcare System, West Haven, CT
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Mayur M Desai
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Dowin Boatright
- Department of Emergency Medicine, New York University School of Medicine, New York, NY
| | - Paris D Butler
- Department of Surgery, Yale School of Medicine, New Haven, CT
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O'Sullivan L, Kagabo W, Prasad N, Laporte D, Aiyer A. Racial and Ethnic Bias in Medical School Clinical Grading: A Review. JOURNAL OF SURGICAL EDUCATION 2023; 80:806-816. [PMID: 37019709 DOI: 10.1016/j.jsurg.2023.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/26/2023] [Accepted: 03/17/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Improving diversity in healthcare is a widely recognized national goal. The diversity of medical student matriculants has increased, yet this trend is not seen in the composition of competitive residency programs. In this review, we examine racial and ethnic disparities in medical student grading during clinical years and explore the consequences of how this may exclude minority students from accessing competitive residency positions. DESIGN Following PRISMA guidelines, we searched PubMed, Embase, Scopus, and ERIC databases using variations of the terms "race," "ethnicity," "clerkship," "rotation," "grade," "evaluation", or "shelf exam." Of 391 references found using the criteria, 29 were related to clinical grading and race/ethnicity and included in the review. The GRADE criteria were used to determine the quality of evidence. SETTING Johns Hopkins School of Medicine, Baltimore MD. RESULTS Five studies examining a total of 107,687 students from up to 113 different schools found racial minority students receive significantly fewer Honors grades in core clerkships compared to White students. Three studies examining 94,814 medical student evaluations from up to 130 different schools found significant disparities in the wording of written clerkship evaluations based on race and/or ethnicity. CONCLUSIONS A large body of evidence suggests the presence of racial bias in subjective clinical grading and written clerkship evaluations of medical students. Grading disparities can disadvantage minority students when applying to competitive residency programs and may contribute to a lack of diversity in these fields. As low minority representation has a negative impact on patient care and research advancement, strategies to resolve this issue must be further explored.
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Affiliation(s)
- Lucy O'Sullivan
- Johns Hopkins Orthopedics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Whitney Kagabo
- Department of Orthopedics, Johns Hopkins Orthopedics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Niyathi Prasad
- Department of Orthopedics, Johns Hopkins Orthopedics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Dawn Laporte
- Department of Orthopedics, Johns Hopkins Orthopedics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Amiethab Aiyer
- Department of Orthopedics, Johns Hopkins Orthopedics, Johns Hopkins Medicine, Baltimore, Maryland
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Shaffrey EC, Moura SP, Wirth PJ, Attaluri PK, Schappe A, Edalatpour A, Bentz ML, Rao VK. Objective Residency Applicant Assessment Using a Linear Rank Model. JOURNAL OF SURGICAL EDUCATION 2023; 80:776-785. [PMID: 37012141 DOI: 10.1016/j.jsurg.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES Residency applicant assessment is imperfect, with little objectivity built into the process, which, unfortunately, impacts recruitment diversity. Linear rank modeling (LRM) is an algorithm that standardizes applicant assessment to model expert judgment. Over the last 5 years, we have used LRM to assist with screening and ranking integrated plastic surgery (PRS) residency applicants. This study's primary objective was to determine if LRM scores are predictive of match success and, secondarily, to compare LRM scores between gender and self-identified race categories. DESIGN Data was collected on applicant demographics, traditional application metrics, global intuition rank, and match success. LRM scores were calculated for screened and interviewed applicants, and scores were compared by demographic groups. Univariate logistic regression was used to evaluate the association of LRM scores and traditional application metrics with match success. SETTING University of Wisconsin, Division of Plastic and Reconstructive Surgery. Academic institution. PARTICIPANTS Six hundred seventeen candidates who applied to a single institution over 4 application cycles (2019-2022). RESULTS Using area under the curve modeling, LRM score was the most predictive indicator for match success. With every one-point increase in LRM score, there was an 11% and 8.3% increase in the likelihood of screened and interviewed applicant match success (p < 0.001). An algorithm was developed to estimate the probability of match success based on LRM score. No significant differences in LRM scores were appreciated for interviewed applicant gender or self-identified race groups. CONCLUSIONS LRM score is the most predictive indicator of match success for PRS applicants and can be used to estimate an applicant's probability of successfully matching into an integrated PRS residency. Furthermore, it provides a holistic evaluation of the applicant that can streamline the application process and improve recruitment diversity. In the future, this model could be applied to assist in the match process for other specialties.
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Affiliation(s)
- Ellen C Shaffrey
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Steven P Moura
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Peter J Wirth
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Pradeep K Attaluri
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Alyssa Schappe
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Armin Edalatpour
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Michael L Bentz
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin
| | - Venkat K Rao
- Division of Plastic and Reconstructive Surgery, University of Wisconsin School of 11 Medicine and Public Health, Madison, Wisconsin.
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Nguyen M, Gonzalez L, Chaudhry SI, Ahuja N, Pomahac B, Newman A, Cannon A, Zarebski SA, Dardik A, Boatright D. Gender Disparity in National Institutes of Health Funding Among Surgeon-Scientists From 1995 to 2020. JAMA Netw Open 2023; 6:e233630. [PMID: 36939702 PMCID: PMC10028489 DOI: 10.1001/jamanetworkopen.2023.3630] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/30/2023] [Indexed: 03/21/2023] Open
Abstract
Importance Surgical diseases account for approximately 30% of the global burden of disease. Gender diversity in biomedical research is critical to generate innovative patient-centered research in surgery. Objective To examine the distribution of biomedical research funding by the National Institutes of Health (NIH) among women and men surgeon-scientists during a 25-year period. Design, Setting, and Participants This cross-sectional study used publicly available data from the NIH RePORTER (Research Portfolio Online Reporting Tools: Expenditures and Results) database for research project grants awarded to women and men surgeon-scientists who were principal investigators between 1995 and 2020. Data were retrieved between January 20 and March 20, 2022. The representation of women surgeon-scientists among academic surgeons was compared with the representation of men surgeon-scientists over time. Main Outcomes and Measures Distribution of NIH funding to women and men surgeon-scientists was examined via 2 metrics: holding a large-dollar (ie, R01-equivalent) grant and being a super principal investigator (SPI) with $750 000 or more in total annual research funding. Statistical analysis was performed between April 1 and August 31, 2022. Results Between 1995 and 2020, 2078 principal investigator surgeons received funding from the NIH. The proportion of women academic surgeons who were surgeon-scientists remained unchanged during this same period (1995, 14 of 792 [1.8%] vs 2020, 92 of 3834 [2.4%]; P = .10). Compared with their men counterparts, women surgeon-scientists obtained their first NIH grant earlier in their career (mean [SD] years after first faculty appointment, 8.8 [6.2] vs 10.8 [7.9] years; P < .001) and were as likely to obtain large-dollar grants (aRR, 0.99 [95% CI, 0.95-1.03]) during the period 2016 to 2020. Despite this success, women surgeon-scientists remained significantly underrepresented among SPIs and were 25% less likely to be an SPI (aRR, 0.75 [95% CI, 0.60-0.95] during the period 2016 to 2020). Conclusions and Relevance The findings of this cross-sectional study of NIH-funded surgeons suggest that women surgeons remained underrepresented among surgeon-scientists over a 25-year period despite early career success in receiving NIH funding. This is concerning and warrants further investigation to increase the distribution of NIH funding among women surgeon-scientists.
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Affiliation(s)
| | | | - Sarwat I. Chaudhry
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Department of Biological and Biomedical Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ashley Newman
- Howard University School of Medicine, Washington, DC
| | - Ashley Cannon
- Technical Resources International, Bethesda, Maryland
| | | | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Biological and Biomedical Sciences, Yale School of Medicine, New Haven, Connecticut
- Department of Surgery, VA Connecticut Healthcare System, West Haven
| | - Dowin Boatright
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
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Carter BD, Badejo MA, Ogola GO, Waddimba AC, Fleshman JW, Harrington MA. National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study. Am J Surg 2023; 225:1000-1008. [PMID: 36646598 DOI: 10.1016/j.amjsurg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/25/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs. METHODS We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance. RESULTS Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated. CONCLUSIONS Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.
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Affiliation(s)
- Brittany D Carter
- General Medical Education, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA.
| | - Megan A Badejo
- College of Medicine, Texas A & M University Health Science Center, Dallas Campus, Texas, USA.
| | - Gerald O Ogola
- Division of Surgical Research, Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA.
| | - Anthony C Waddimba
- Division of Surgical Research, Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA.
| | - James W Fleshman
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA.
| | - Melvyn A Harrington
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA.
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Aranda-Michel E, Trager LE, Han JJ, Aggarwal R, Cevasco M, Kelly RF, Sultan I. Considerations for a Holistic Model in Evaluating Medical Students for Cardiothoracic Surgical Residency. Semin Thorac Cardiovasc Surg 2022; 35:705-710. [PMID: 35714822 DOI: 10.1053/j.semtcvs.2022.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 11/11/2022]
Abstract
Program directors are tasked with selecting whom they think will be the best fit for residency and the next leaders of the field. While numerical metrics have played a vital role in this process, recent changes to student evaluation are reducing the availability of these metrics. This poses unique challenges for both applicants and program directors. Here we discuss how this will likely shift the focus on other parts of the application and the consequences (good and bad) of doing so.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lena E Trager
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Jason J Han
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
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