Representation remains low in internal medicine residency

Between 2010 and 2018, representation of applicants and matriculants from underrepresented racial and ethnic groups remained low in internal medicine residency programs, according to a study in Annals of Internal Medicine.

“Previous research has detailed the importance of a racially and ethnically diverse physician workforce in improving access to care, communication, patient satisfaction, and health outcomes, particularly for underserved and systemically marginalized patients,” Joanna Liao, BS, of the University of Washington School of Medicine in Seattle, and colleagues wrote. “Despite this need, disparities in representation within medicine, including internal medicine (IM), persist.”

Using data from the Association of American Medical Colleges, Liao and colleagues reviewed race and ethnicity data for 214,656 applicants and 87,489 matriculants to Accreditation Council for Graduate Medical Education IM residencies between July 2010 and July 2018. Applicants and matriculants identifying as American Indian or Alaska Native; Black or African American; Hispanic, Latino or of Spanish origin; or Native Hawaiian or Pacific Islander were considered underrepresented in medicine (UIM).

The proportion of UIM applicants and matriculants “grew minimally but significantly” over the 8-year period examined, though only 28,222 applicants (13.2%) and 9,269 matriculants (10.6%) identified as UIM in that time.

Stratified analysis revealed a statistically significant increase in applicants identifying as Black or African American (slope, 0.11; 95% CI, 0.29-0.39) and those identifying as Hispanic, Latino or of Spanish origin (slope, 0.22; 95% CI, 0.15-0.29). Among matriculants, a significant increase was only seen for those identifying as Hispanic, Latino or of Spanish origin (slope, 0.13; 95% CI, 0.05-0.21).

Additionally, the proportion of matriculants who were white was greater than that among applicants with each successive year.

“Despite efforts to increase representation, the percentage of aggregate UIM applicants and matriculants to IM has remained low over time,” Liao and colleagues wrote. “Limiting factors include the small percentage of UIM medical school graduates from which to draw diverse resident applicants. Similarly, the stark disparities in UIM faculty representation are concerning, as faculty are often positioned to enact the changes needed in residency admission processes.”

In a related editorial, Spencer V. Carter, MD, and Quinn Capers IV, MD, both of the department of internal medicine and division of cardiology at the University of Texas Southwestern Medical Center, highlighted factors that may contribute to the lower proportion of UIM matriculants, including the high values that IM program directors place on standardized test scores, which correlate with family income and parental education level and “favor white test takers.” Other factors include bias that prevent UIM students from receiving:

• Alpha Omega Alpha honor society membership;
• acceptance at highly ranked medical schools;
• positive recommendation letters; and
• high clerkship grades.

They also noted that some directors of IM residency programs may consider diversity a low priority.

Carter and Capers suggested reforms to these barriers, such as revising selection processes to be more equitable and putting more emphasis on diversity.

“These changes will be challenging, time-consuming and resource-consuming, and will require recruiting more persons onto selection and interview teams that both represent and prioritize the diversity that we desire in our trainees,” they wrote. “It is time to rethink the Gate and the Gatekeepers.”