Researchers identify interventions to improve diversity in medical training

A combination of concrete interventions could help increase the proportion of historically underrepresented individuals in medical training, according to researchers.

“Underrepresentation of Black or African American, Hispanic or Latinx, Native Hawaiian or Pacific Islander, American Indian or Alaska Native, and certain Southeast Asian subgroups persists in medicine, with complex and multifactorial causes signaling the urgent need for widespread solutions,” Russyan Mark Mabeza, MPH, a medical student at the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues wrote in JAMA Network Open.

Mabeza told Healio that it is important to increase racial and ethnic diversity in medical education because diversity leads to innovation “and health care improves when multiple perspectives are taken into account in solution-finding, decision-making and project execution.”

“While these reasons are valid, increasing racial and ethnic diversity in medical education is also important because it is simply the right thing to do,” Mabeza said. “It is a necessary measure to counteract the history and legacy of racism that has historically excluded various groups in medicine.”

The researchers sought to understand interventions that have been used to increase the proportions of underrepresented in medicine (URiM) trainees at residency and fellowship programs in the United States.

“Our review provides a collection of evidence-based diversity initiatives organized across various stages of the [graduate medical education (GME)] recruitment process,” they wrote. “As more programs move toward diversity, equity and inclusion, this compendium of interventions can be used as a starting framework for program directors, trainee selection committees and GME support staff to organize their own efforts to diversify their programs.”

For the scoping review, the researchers searched the following databases to identify relevant studies: CINAHL, Cochrane Reviews, Cochrane Trials, Embase, ERIC, Google Scholar, PROSPERO, PsycInfo, PubMed and Scopus.

They ultimately included 27 articles in the final analysis. Among them, 19 focused on efforts in medical specialties and nine focused on surgical specialties. In addition, six articles were in emergency medicine, and there were three articles each in family medicine and pediatrics.

The most common interventions the researchers found were holistic review, at 48%, and a decreased emphasis on United States Medical Licensing Examination (USMLE) Step 1 scores, also at 48%.

“USMLE Step 1 score filters disproportionately affect URiM applicants. Yet, for many specialties, Step 1 scores continue to be an important factor in selecting candidates,” they wrote. “The transition of the Step 1 exam to pass/fail may mitigate the systematic exclusion of URiM applicants in GME recruiting.”

However, Mabeza and colleagues said it might also lead to “overreliance on other traditional metrics of evaluation, including school ranking and Alpha Omega Alpha status, both of which have been shown to disadvantage URiM candidates.”

“Holistic review was one of the most common interventions we found in the reviewed studies. A big component of this approach is de-emphasizing, even eliminating, standardized test scores as a screening metric,” Mabeza told Healio. “When programs evaluate for attributes that reflect their departments' mission, URiM applicants have a fairer shot of demonstrating their qualifications.”

The other most common intervention, at 37%, was explicit institutional messaging regarding the importance of diversity.

Combining interventions was linked to a higher number of URiM applicants, matriculants and interviewees across various specialties, according to the researchers.

“Mentorship programs that allow URiM students to build skills, immerse in clinical experiences, and participate in research opportunities may be effective in increasing the interest and competitiveness of URiM medical students,” they wrote. “Visiting clerkships or even intentionally curated virtual experiences can increase exposure of URiM students to training programs.”

Mabeza and colleagues highlighted the importance of tangible action.

“While intentional mission statements articulating commitment to diversity, equity, and inclusion are important for URiM students, our review demonstrates that concrete actions to actualize this mission are paramount,” they wrote. “Interacting with URiM faculty and trainees can be a powerful avenue to discuss opportunities within the program and address URiM-specific concerns. This effort requires commitment from home departments to recruit and retain URiM faculty and staff.”

Study coauthor Jasmine Marcelin, MD, an associate professor of infectious diseases and associate program director of the internal medicine residency at University of Nebraska Medical Center, told Healio that “transforming GME training programs is a process that requires a long-term vision beginning with a lens of equity.”

“Programs must recognize the importance of committing resources to the goal of developing training programs with trainees who represent the patients they serve,” Marcelin said. “Attention should be paid to each area in the process (recruiting, application review, interviewing, ranking) before trainees matriculate, and once they achieve diverse representation, programs must continue working to maintain an inclusive environment where all trainees feel they can belong and thrive.”

The researchers concluded that “continued efforts are necessary to sustain such efforts and assess long-term outcomes” and “future research is needed to discover how these initiatives change trainee demographic characteristics over longer periods and to understand the full costs associated with operationalizing these interventions.”

“Fundamentally, a cultural shift is needed in institutions toward prioritizing representation of historically excluded groups in medicine,” they wrote. “When diversity and inclusion are explicitly stated institutional goals, they serve as a basis for making concrete changes that drive effective recruitment of URiMs into GME programs. While programs considerably vary in size and culture, dedicated resources serve as a unifying thread. As such, any institution with serious aims of recruiting more URiM trainees must commit time, personnel and financial resources toward this effort.”