Mission matters: Association between a medical school's mission and minority student representation

The Relationship Between the Social Mission Content of Medical School Mission Statements and Minority Faculty Representation Among Faculty and Senior Leadership

Medical schools with social missions have the potential to increase minority student interest in health disparities research. In previous work, the authors looked at the missions of medical schools to determine if they were associated with minority student representation. In this paper, the authors look at the representation of full-time faculty and senior leaders who are underrepresented in medicine in US medical schools. This study included all MD-granting medical schools in the US with available data on mission statement Social Mission Content (SMC) and faculty demographics. Data were analyzed for representation of faculty underrepresented in medicine (URM) among all faculty, among junior as compared to senior faculty, and among department chairs. In the 2013 data, Pearson correlation coefficients were calculated to characterize the association between SMC and contemporaneous URM faculty representation. In the 2014-2020 data, hierarchical linear models were used to estimate the association between SMC and the annual rate of change in URM faculty representation. In 2013, URM faculty accounted for 7.4% of all faculty at the median medical school, increasing to 8.4% in 2020. As of 2013, URM representation among junior faculty was 9.2% at the median school, 5.6% among senior faculty, and 4.3% among department chairs. The authors found a slow increase in the percentage of URM faculty members (but not department chairs). This trend did not vary between schools with lower vs. higher emphasis on a social mission (based on the mission statement). The increase in chair representation was determined to be associated with the type of the school, whether historically Black or Puerto Rican, and not precisely its mission.

"What's Next in My Arc of Development?": An Exploratory Study of What Medical Students Need to Care for Patients of Different Backgrounds

PHENOMENON

Medical schools must equip future physicians to provide equitable patient care. The best approach, however, is mainly dependent on a medical school's context. Graduating students from our institution have reported feeling ill-equipped to care for patients from "different backgrounds" on the Association of American Medical Colleges' Graduation Questionnaire. We explored how medical students interpret "different patient backgrounds" and what they need to feel prepared to care for diverse patients.

APPROACH

We conducted an exploratory qualitative case study using focus groups with 11, Year 2 (MS2) and Year 4 (MS4) medical students at our institution. Focus groups were recorded, transcribed, and coded using thematic analysis. We used Bobbie Harro's cycles of socialization and liberation to understand how the entire medical school experience, not solely the curriculum, informs how medical students learn to interact with all patients.

FINDINGS

We organized our findings into four major themes to characterize students' medical education experience when learning to care for patients of different backgrounds: (1) Understandings of different backgrounds (prior to medical school); (2) Admissions process; (3) Curricular socialization; and (4) Co-curricular (or environmental) socialization. We further divided themes 2, 3, and 4 into two subthemes when learning how to care for patients of different backgrounds: (a) the current state and (b) proposed changes. We anticipate that following the proposed changes will help students feel more prepared to care for patients of differing backgrounds.

INSIGHTS

Our findings show that preparing medical students to care for diverse patient populations requires a multitude of intentional changes throughout medical students' education. Using Harro's cycles of socialization and liberation as an analytic lens, we identified multiple places throughout medical students' educational experience that are barriers to learning how to care for diverse populations. We propose changes within medical students' education that build upon each other to adequately prepare students to care for patients of diverse backgrounds. Each proposed change culminates into a systemic shift within an academic institution and requires an intentional commitment by administration, faculty, admissions, curriculum, and student affairs.

Diversity in Mission Statements and Among Students at US Medical Schools Accredited Since 2000

Importance

Diversity in the physician workforce improves patient care and decreases health disparities. Recent calls for social justice have highlighted the importance of medical school commitment to diversity and social justice, and newly established medical schools are uniquely positioned to actively fulfill the social mission of medicine.

Objective

To identify diversity language in the mission statements of all medical schools accredited since 2000 and to determine whether the presence of diversity language was associated with increased diversity in the student body.

Design, Setting, and Participants

Cross-sectional study of public websites conducted between January 6, 2023, and March 31, 2023. Qualitative content analysis of mission statements was conducted using a deductive approach. Eligible schools were identified from the 2021-2022 Medical School Admission Requirements and American Medical Colleges and American Association of Colleges of Osteopathic Medicine websites. Each school's publicly available website was also reviewed for its mission and student body demographics. All United States allopathic and osteopathic medical schools that have been accredited and have enrolled students since 2000.

Exposure

Content analysis of medical school mission statements.

Main Outcomes and Measures

Prevalence of diversity language in medical school mission statements and its association with student body racial diversity. Data were analyzed in 5-year groupings: 2001 to 2005, 2006 to 2010, 2011 to 2015, and 2016 to 2020).

Results

Among the 60 new medical schools (33 [55%] allopathic and 27 [45%] osteopathic; 6927 total students), 33 (55%) incorporated diversity language into their mission statements. In 2022, American Indian or Alaska Native individuals accounted for 0.26% of students (n = 18), Black or African American students constituted 5% (n = 368), and Hispanic or Latinx individuals made up 12% (n = 840). The percentage of schools with diversity language in their mission statements did not change significantly in schools accredited across time frames (60% in 2001: mean [SE], 0.60 [0.24] vs 50% in 2020: mean [SE], 0.50 [0.11]). The percentage of White students decreased significantly over the time period (26% vs 15% students in 2001-2005 and 2016-2020, respectively; P < .001). No significant differences were observed in student body racial or ethnic composition between schools with mission statements that included diversity language and those without.

Conclusions and Relevance

In this cross-sectional study of US medical schools accredited since 2000, diversity language was present in approximately half of the schools' mission statements and was not associated with student body diversity. Future studies are needed to identify the barriers to increasing diversity in all medical schools.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Diversity in the pediatric research workforce: a scoping review of the literature

The purpose of this scoping review is to determine trends in racial and ethnic representation, identify barriers and facilitators to greater diversity, and assess strategies and interventions to advance diversity among those in the pediatric research workforce in the U.S. We conducted a scoping review of PubMed supplemented with the authors' personal library of papers published from January 1, 2010, to December 31, 2021. To be eligible, papers had to provide original data, be published in English, report information from a U.S. healthcare institution, and report on outcomes of interest relevant to the child health field. The diversity of faculty has modestly increased over the past decade but reflects a worsening representation compared to overall population trends. This slow increase reflects a loss of diverse faculty and has been referred to as a "leaky pipeline." Strategies to plug the "leaky pipeline" include greater investments in pipeline programs, implementation of holistic review and implicit bias training, development of mentoring and faculty programs targeted to diverse faculty and trainees, alleviation of burdensome administrative tasks, and creation of more inclusive institutional environments. Modest improvements in the racial and ethnic diversity of the pediatric research workforce were identified. However, this reflects worsening overall representation given changing U.S. population demographics. IMPACT: Racial and ethnic diversity in the pediatric research workforce has shown modest increases but worsening overall representation. This review identified barriers and facilitators at the intrapersonal, interpersonal, and institutional levels that impact BIPOC trainees and faculty career advancement. Strategies to improve the pathway for BIPOC individuals include greater investments in pipeline and educational programs, implementation of holistic review admissions and bias training, institution of mentoring and sponsorship, alleviation of burdensome administrative responsibilities, and creation of inclusive institutional climates. Future studies should rigorously test the effects of interventions and strategies designed to improve diversity in the pediatric research workforce.

Website mission statements of dermatology residency programs: a cross-sectional study

Recent calls for increased transparency from dermatology residency programs have revealed important opportunities, particularly including information on program websites. One piece of information that may especially benefit applicants assessing potential training programs is the program's mission statement. From August 9, 2022, to August 21, 2022, the websites of all ACGME-accredited dermatology residencies were examined to investigate the use and content of mission statements. Statements were categorized based on inclusion of mission, vision, virtue/value, aims, and goals. A total of 133 out of 143 dermatology programs (93.0%) were included. Overall, 46.15% of programs used at least one of the five mission statement categories on their websites, while 53.85% used none. Programs used the category "mission" (39.85%) most, and "vision" (3.01%) least. There was overlap in word choice across categories. The word "care" was among the top four words used in every category. Other words to appear frequently across multiple categories included "dermatology" (4/5), "residents" (3/5), "knowledge" (2/5), and "provide" (2/5). Other top words included "clinical" in the mission category, "advanced" and "leaders" in the vision category, "excellence" and "diversity" in the value/virtue category, and "patient" and "professional" in the objective category. Explicitly stating residency program missions may not only help programs plan more effectively, but also help applicants who may be undecided about which programs best align with their career goals.

Changing Missions of Medical Schools and Trends in Medical Student Diversity

BACKGROUND AND OBJECTIVES

Improving diversity in the physician workforce continues to be a challenge and a priority for medical schools. Establishing a school-wide mission statement that addresses diversity, equity, and inclusion can help support efforts to increase the number of underrepresented in medicine (URM) graduates.

METHODS

In this study, we analyzed changes in medical school mission statements between 2013 and 2021 and correlated changes in mission statements with trends in URM student representation. We performed a web search of 136 medical schools' mission statements and categorized them based on whether they changed their mission statement to add diversity or equity language. We then obtained demographic data of enrolled students at each school and identified the percentage of students identifying as URM in each academic year. We used mixed-effects regression and pair fixed effects linear regression to examine trends in URM student representation and the association between URM student representation and whether a school added diversity and equity content to its mission statement.

RESULTS

We found that URM student representation increased by 0.4% per year at schools that added diversity and equity content to their mission statements.

CONCLUSIONS

Changing medical schools' mission statements to reflect values of diversity, equity, and inclusion was associated with an increase of less than a 1% per year in URM representation. More research is needed to explore relationships between URM representation and medical school mission statements.

US Medical School Admissions Leaders' Experiences With Barriers to and Advancements in Diversity, Equity, and Inclusion

IMPORTANCE

Despite decades-long calls for increasing racial and ethnic diversity, the medical profession continues to exclude members of Black or African American, Hispanic or Latinx, and Indigenous groups.

OBJECTIVE

To describe US medical school admissions leaders' experiences with barriers to and advances in diversity, equity, and inclusion.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study involved key-informant interviews of 39 deans and directors of admission from 37 US allopathic medical schools across the range of student body racial and ethnic composition. Interviews were conducted in person and online from October 16, 2019, to March 27, 2020, and analyzed from October 2019 to March 2021.

MAIN OUTCOMES AND MEASURES

Participant experiences with barriers to and advances in diversity, equity, and inclusion.

RESULTS

Among 39 participants from 37 medical schools, admissions experience ranged from 1 to 40 years. Overall, 56.4% of participants identified as women, 10.3% as Asian American, 25.6% as Black or African American, 5.1% as Hispanic or Latinx, and 61.5% as White (participants could report >1 race and/or ethnicity). Participants characterized diversity broadly, with limited attention to racial injustice. Barriers to advancing racial and ethnic diversity included lack of leadership commitment; pressure from faculty and administrators to overemphasize academic scores and school rankings; and political and social influences, such as donors and alumni. Accreditation requirements, holistic review initiatives, and local policy motivated reforms but may also have inadvertently lowered expectations and accountability. Strategies to overcome challenges included narrative change and revision of school leadership structure, admissions goals, practices, and committee membership.

CONCLUSIONS AND RELEVANCE

In this qualitative study, admissions leaders characterized the ways in which entrenched beliefs, practices, and power structures in medical schools may perpetuate institutional racism, with far-reaching implications for health equity. Participants offered insights on how to remove inequitable structures and implement process changes. Without such action, calls for racial justice will likely remain performative, and racism across health care institutions will continue.

Words matter: Tracing the implicit meaning of diversity language (and its absence) in medical school mission statements

Despite recent attention to social justice, diversity, equity, and inclusion within medical education, little is currently known about whether and to what extent that attention has translated into the language of formal documents articulating organization purpose: medical school mission statements. Mission statements are the marquee declaration of a medical school's identity and purpose, and a recommended tool for applicants to determine "fit" when applying. This study examines whether and to what extent social justice, diversity, equity, and inclusion have made it into the formal public statements of organizational purpose and identity over the last several years. Mission statements were extracted manually from the 2007, 2017, and 2021 AAMCs Medical School Admission Requirements (MSAR) database for both U.S. and Canadian M.D. granting medical schools. Then each mission statement version was coded for the presence and degree of diversity language including words like social justice, diversity, equity, and inclusion using an agreed-upon lexicon. Frequencies and within school changes over time were analyzed. Among 139 medical schools with discoverable mission statements from 2007, 91% (n=127) changed their MSs between 2007 and 2021. In 2007, 24% (n=33) of MSs contained diversity language. By 2017 nearly half of MSs; 47% (n=65) contained any reference to such language. But by 2021, despite 46 school having changed their MSs again, only a few more included diversity language in their MSs (56%; n=77). The most common terms used were "diversity," followed by the increasing presence of words like "inclusion," "equity," and "justice" by 2021. Curiously, a few schools redacted diversity language from 2007 to 2021. A Diversity Thesaurus of 22 terms was iteratively identified, with all terms searched in all MSs. Overall, mission statement change was quite common with most medical schools making changes across the 14 years covered in this study. And despite a doubling of the number of medical schools MSs mentioning diversity over a 10-year period, that increase seemed to slow in recent years even among schools who had a chance to change their MS. As of mid-2021, two in five US medical schools still have no mention of diversity related language in their most formal, said articulation of organizational purpose.

What is the mission of innovation?—Lexical structure, sentiment analysis, and cosine similarity of mission statements of research-knowledge intensive institutions

Mission statements (henceforth: missions) are strategic planning communication tools used by all types of organizations worldwide. Missions communicate an organization’s purpose, values, standards, and strategy. Research on missions has been prolific over the past 30 years, nevertheless several empirical gaps remain, such as single sector or country studies and restricted mission samples. In this article, we identify similarities and differences in the content of missions from government, private, higher education, and health research-knowledge intensive institutions in a sample of 1,900+ institutions from 89 countries through the deployment of sentiment analysis, readability, and lexical diversity; semantic networks; and a similarity computation between document corpus. We found that missions of research-knowledge intensive institutions are challenging to read texts with lower lexical diversity that favors positive rather than negative words. In stark contrast to this, the non-profit sector is consonant in multiple dimensions in its use of Corporate Social Responsibility jargon. The lexical appearance of ‘research’ in the missions varies according to mission sectorial context, and each sector has a cluster-specific focus. Utilizing the mission as a strategic planning tool in higher-income regions might serve to explain corpora similarities shared by sectors and continents. Furthermore, our open-access dataset on missions worldwide can be used as a source for further replication, triangulation, or crowdsourcing-data studies. Also, practitioners could use our open-access dataset and insights to facilitate strategic planning activities in organizations from multiple sectors.

Implementing High-Quality Primary Care Through a Health Equity Lens

The COVID-19 pandemic highlighted the importance of centering health equity in future health system and primary care reforms. Strengthening primary care will be needed to correct the longstanding history of mistreatment of First Nations/Indigenous and racialized people, exclusion of health care workers of color, and health care access and outcome inequities further magnified by the COVID-19 pandemic. The National Academies of Sciences, Engineering, and Medicine (NASEM) released a report on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, that provided a framework for defining high-quality primary care and proposed 5 recommendations for implementing that definition. Using the report's framework, we identified health equity challenges and opportunities with examples from primary care systems in the United States and Canada. We are poised to reinvigorate primary care because the recent pandemic and the attention to continued racialized police violence sparked renewed conversations and collaborations around equity, diversity, inclusion, and health equity that have been long overdue. The time to transition those conversations to actionable items to improve the health of patients, families, and communities is now.Appeared as Annals "Online First" article.