Q&A: Selecting family medicine residency candidates based on resiliency improves diversity
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Key takeaways:
- Reevaluating the rubric used to select residency candidates for interviews improved the diversity of a family medicine residency program.
- Healio spoke with the leaders of the intervention to learn more.
An intervention can increase the racial and ethnic diversity of applicants in family medicine residency programs without using race or ethnicity as a factor, according to experts.
Kirsten Stoesser, MD, an associate professor and director of the family medicine residency program at the University of Utah, and José E. Rodríguez, MD, FAAFP, a family physician and associate vice president for health equity, diversity and inclusion at the University of Utah Health, recently published a perspective in The New England Journal of Medicine on their efforts toward health equity in medical education.
Despite Salt Lake City’s increasing population of people from underrepresented ethnic groups, the University of Utah’s family medicine residency program — the largest in the state — had few residents who identified as underrepresented in medicine, they wrote.
Stoesser and Rodríguez wrote that “in order to ensure that we train a physician workforce that can optimally meet the needs of our diverse patient population,” they evaluated and revised the rubric that was used to choose residency candidates for interviews.
Notably, the revised rubric did not factor race or ethnicity, but rather opted for resiliency. The ability to persevere in the face of adversity is a quality in the best residents, according to Rodríguez, and it is common that those students are underrepresented in medicine.
This intervention, they wrote, led to more residents who identified as underrepresented in medicine interviewing for the program — the interviews of these candidates rose from 3% (two candidates) to 34% (33 candidates) from 2017 to 2021.
Healio spoke with Stoesser and Rodríguez to learn more about the intervention, the importance of racial and ethnic diversity in family medicine and more.
Healio: You wrote that, before the intervention, very few applicants who were underrepresented in medicine were being selected to interview. Why do you think this was? Is this part of a larger, more systemic issue?
Stoesser: I believe this was multifactorial. At a program level, it was not intentional that we were not selecting proportionally as many underrepresented applicants. However, the systems in place for applicant review were, in retrospect, favoring certain aspects of an application over other aspects. There is also a larger, more systemic issue, in that residency programs overall are limited in the number of underrepresented applicants that ultimately train at our programs based on the number of underrepresented applicants being admitted to, and graduating from, medical schools. A truly effective intervention needs to start from the medical school admissions level.
Healio: Why did you decide to work on this intervention? Why is diversity in family medicine residency so important?
Stoesser: We know that populations do better when they have physicians and other health care providers from similar backgrounds providing care for them. Health outcomes are better across multiple measures. This may not always even be a direct effect between a physician and a patient — having physicians from different backgrounds in an organization and in a community helps to create increased awareness among their practice partners as well. We also know that the demographics of our physician health care workforce in this country do not closely enough match the demographics of our underrepresented communities. This mismatch also exists in Utah, and being in Utah, we saw this as an opportunity to improve the health care outcomes in our state, by graduating more physicians from different backgrounds to serve our state and region. In particular, for primary care and for specialty care, the number of physicians who identify as Black, Hispanic, American Indians and Alaskan Natives, Native Hawaiians and other Pacific Islanders are underrepresented compared to the numbers of people in the population. Having more physicians from these varied racial and ethnic backgrounds will help to improve the health of our diverse communities.
Rodríguez: In addition, racial and ethnic concordance between providers has been shown to improve health outcomes and reduce care costs.
It is important to mention that the rubric selects for resiliency. We have learned that the best residents are those who can get up after they fall or are pushed down. This kind of grit is useful for them to stay in the program. It is also very common in those students who come from backgrounds that are traditionally underrepresented in medicine.
Healio: Will you briefly describe the intervention and findings? Why are your findings important?
Stoesser: Our intervention involved having a revised systematic way to review applications to residency that was a more comprehensive and holistic method than prior. In our new method, we provided less emphasis on top academic performance, and placed an increased emphasis on looking at factors that indicated an individual’s lived experiences and resiliency, including looking at resiliency in the context of socioeconomic factors. These are factors that, in addition to academic competence, are crucial for being an effective physician. Notably, our method did not use race or ethnicity as a factor in reviewing applicants, and it demonstrated that one can increase the diversity of applicants invited to interview by changing the way we value applicant experiences.
Healio: Are your findings generalizable? Do you think this intervention would work outside of Utah?
Stoesser: Yes, our findings are generalizable and could be applied to any other program, whether inside or outside of Utah and in specialties other than family medicine and primary care. However, a current barrier is that there is a rate-limiting factor in the number of applicants from underrepresented backgrounds being accepted into medical schools. All of the residency programs are competing among the same pool of applicants. So, in effect, certain programs can make themselves more attractive as a place supportive of training applicants from diverse backgrounds, and more applicants may choose to rank those programs highly and match into those sites. However, the overall number of resident physicians from underrepresented backgrounds in medicine is still overwhelmingly dependent on the number of medical students from underrepresented backgrounds in each graduating medical school class every year.
Healio: Is there anything else you’d like to add?
Stoesser: In order to get more students from underrepresented backgrounds into medicine, this really needs to start at the college, high school, and even grade school levels. This is why programs at these levels are so important — every step is important at helping kids along this pathway to becoming a physician. Programs can involve outreach, encouragement, science and math preparation, and mentorship. And perhaps it all starts with a moment of inspiration, where a student sees or works with a physician with a similar background as them, and they are inspired to take the same path, believing that if it was possible for that person, then it could be possible for them.
Rodríguez: Our successes at University of Utah Health in this area are based on improving the pathway programs, providing strong support, and helping students from multiple diverse backgrounds, including those from lower socioeconomic status and from educationally disadvantaged backgrounds, see themselves here.