Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation

The presence, action, and influence of bystanders who witness sexual harassment against medical students

PURPOSE

Sexual harassment (SH) is a widespread problem in academia, with a disproportionate impact on female medical students and those who experience marginalization via multiple systems of oppression (e.g. racism, heterosexism). Bystander intervention education is a potential approach which frames violence as a community issue where all members have a role to play in response and prevention. This study assessed the presence and influence of bystanders in SH situations for students at two medical schools.

MATERIALS AND METHODS

Data came from a larger U.S. campus climate study administered online in 2019 and 2020. The sample included 584 students who responded to validated survey questions about sexual harassment experiences, bystander behavior, disclosure, perceptions of the university response to SH, and demographics.

RESULTS

More than one-third of respondents experienced some form of SH by a faculty/staff member. Bystanders were present for more than half of these incidents, yet they rarely intervened. When bystanders intervened, people were more likely to disclose an incident than not.

CONCLUSIONS

The results indicate that there are many missed opportunities for intervention and given the profound impact that SH has on the well-being of medical students, continued work is needed to determine effective intervention and prevention methods.[Box: see text].

Experiences with Racism Among Asian American Medical Students

Importance

Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students.

Objective

To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment.

Design, Setting, and Participants

This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years.

Main Outcomes and Measures

The medical school experiences of Asian American medical students.

Results

Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future.

Conclusions and Relevance

In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.

A Novel Narrative Medicine Approach to DEI Training for Medical School Faculty

Problem:Diversity, Equity, and Inclusion (DEI) trainings for medical school faculty often lack self-reflective and pedagogically focused components that may promote incorporation of anti-racism and social justice into medical school curricula. Intervention: A four-session Narrative Medicine (NM) anti-racism program was designed for medical school faculty using critical race theory, phenomenology, and NM methods. Each workshop consisted of a lecture on key NM concepts and a small-group breakout session incorporating group discussion, close reading, and reflective writing. Context: This NM anti-racism program was developed and implemented in April 2021 by two medical students for faculty at an institution in the southeastern U.S. The program was supported by the Office of Inclusive Excellence at the institution and held in collaboration with the institution's medical education teaching academy. Program evaluation consisted of pre- and post-program surveys, which queried participants' previous experiences with DEI and medical humanities programs, perceptions of self-identity and privilege, and confidence in teaching concepts of anti-racism. Of the total program participants (n = 32), 19 completed both surveys (54.3%). Survey data were analyzed using bivariate testing methods and qualitative thematic analysis. Impact: Post-program surveys showed 13 (68.4%) participants felt "somewhat more" or "more" comfortable engaging in concepts of race, and 12 (63.2%) participants felt "somewhat more" or "more" comfortable including topics of race into their teaching compared to before the program. Five themes were generated following qualitative analysis: (1) the value of longitudinal narrative reflection in a small-group setting for DEI work; (2) desire to commit more time to DEI, anti-racist, and social justice work while balancing busy teaching and clinical schedules; (3) the value of storytelling in DEI and anti-racism programming; (4) an understanding of deconstructive and reconstructive work of anti-racism in medicine; and (5) an increased ability to educate and enact change through teaching, activism, and institutional cultural and policy changes. Lessons Learned: This novel NM DEI training for medical school faculty was successful in increasing comfort discussing and teaching concepts of race in the medical school classroom, while providing a uniquely reflective space for personal growth. Participation in this longitudinal reflective experience was limited by physician schedules, therefore efforts to make time to participate in similar longitudinal interventions must be undertaken.

The Long Shadow: A Historical Perspective on Racism in Medical Education

To dismantle racism in U.S. medical education, people must understand how the history of Christian Europe, Enlightenment-era racial science, colonization, slavery, and racism shaped modern American medicine. Beginning with the coalescence of Christian European identity and empire, the authors trace European racial reasoning through the racial science of the Enlightenment into the White supremacist and anti-Black ideology behind Europe's global system of racialized colonization and enslavement. The authors then follow this racist ideology as it becomes an organizing principle of Euro-American medicine and examine how it manifests in medical education in the United States today. Within this historical context, the authors expose the histories of violence underlying contemporary terms such as implicit bias and microaggressions. Through this history, they also gain a deeper appreciation of why racism is so prevalent in medical education and how it affects admissions, assessments, faculty and trainee diversity, retention, racial climate, and the physical environment. The authors then recommend 6 historically informed steps for confronting racism in medical education: (1) incorporate the history of racism into medical education and unmask institutional histories of racism, (2) create centralized reporting mechanisms and implement systematic reviews of bias in educational and clinical activities, (3) adopt mastery-based assessment in medical education, (4) embrace holistic review and expand its possibilities in admissions, (5) increase faculty diversity by using holistic review principles in hiring and promotions, and (6) leverage accreditation to combat bias in medical education. These strategies will help academic medicine begin to acknowledge the harms propagated throughout the history of racism in medicine and start taking meaningful steps to address them. Although the authors have focused on racism in this paper, they recognize there are many forms of bias that impact medical education and intersect with racism, each with its particular history, that deserve their own telling and redress.

Intersectional characterization of emergency department (ED) staff experiences of racism: a survey of ED healthcare workers for the Disrupting Racism in Emergency Medicine (DRiEM) Investigators

INTRODUCTION

The impact of racism on patient outcomes in Emergency Medicine has been examined but there have been few studies exploring the experiences of racism in health care workers. This survey aims to explore the experience of racism by interdisciplinary staff in a tertiary ED. By characterizing the staff experience of racism in the ED, we hope to inform the design of strategies to disrupt racism and ultimately improve the health and wellness of both staff and patients.

METHODS

We conducted a self-administered, cross-sectional survey to explore the reported experience of racism by healthcare workers in a single urban ED in an academic trauma centre. We employed classification and regression tree analyses to evaluate predictors of racism through an intersectional lens.

RESULTS

A majority (n = 200, 75%) of all ED staff reported experiencing interpersonal racism (including physical violence, direct verbal violence, mistreatment and/or microaggressions) in the workplace. Respondents who identified as racialized self-reported significantly more racism at work than white respondents (86% vs. 63%, p < 0.001). Occupation, race, migrant status and age were identified through intersectional machine-learning models to be significantly predictive of the experience of racism. Nearly all respondents felt that the disruption of racism in Emergency medicine is important to them (90%, n = 207) and (93%, n = 214) were willing to participate in further training in anti-racism.

CONCLUSIONS

Racism against interdisciplinary staff working in EDs is common and the burden on healthcare workers is high. Intersections of occupation, race, age and migrant status are uniquely predictive of the experience of racism for EM staff. Interventions to disrupt racism should be informed by intersectional considerations to create a safe working environment and target populations most at risk. ED healthcare workers are willing to take steps to disrupt racism in their workplace and need institutional support to do so.

The impact of underrepresented minority or marginalized identity status on training outcomes of MD-PhD students

Dual-degree MD-PhD programs have historically lacked diversity of race, ethnicity, gender, sexual orientation, and other facets of identity. Like MD- and PhD-granting programs, MD-PhD program training environments are also marked by structural barriers that negatively impact measurable academic outcomes of underrepresented and/or marginalized students in academic medicine (racial and ethnic minority groups considered underrepresented by the National Institute of Health, sexual and gender minorities, individuals with disabilities, and individuals of low socioeconomic status). In this article, we review the existing literature on MD-PhD program disparities affecting students from these groups and provide recommendations grounded on the reviewed evidence. Our literature review identified four generalizable barriers that can impact the training outcomes of students from these marginalized and/or underrepresented groups: 1) discrimination and bias, 2) impostor syndrome and stereotype threat, 3) lack of identity-similar mentors, and 4) suboptimal institutional policies and procedures. We propose goal-oriented interventions that may begin to ameliorate the disparities present in MD-PhD program training environments that affect students from marginalized and/or underrepresented groups in academic medicine.

'A role model is like a mosaic': reimagining URiM students' role models in medical school

BACKGROUND

Role modelling is a widely acknowledged element of medical education and it is associated with a range of beneficial outcomes for medical students, such as contributing to professional identity development and a sense of belonging. However, for students who are racially and ethnically underrepresented in medicine (URiM), identification with clinical role models may not be self-evident, as they have no shared ethnic background as a basis for social comparison. This study aims to learn more about the role models of URiM students during medical school and about the added value of representative role models.

METHODS

In this qualitative study we used a concept-guided approach to explore URiM alumni's experiences with role models during medical school. We conducted semi-structured interviews with ten URiM alumni about their perception of role models, who their own role models were during medical school and why they considered these figures as role models. Sensitizing concepts guided the topic list, interview questions and finally served as deductive codes in the first round of coding.

RESULTS

The participants needed time to think about what a role model is and who their own role models are. Having role models was not self-evident as they had never thought about it before, and participants appeared hesitant and uncomfortable discussing representative role models. Eventually, all participants identified not one, but multiple people as their role model. These role models served different functions: role models from outside medical school, such as parents, motivated them to work hard. Clinical role models were fewer and functioned primarily as examples of professional behaviour. The participants experienced a lack of representation rather than a lack of role models.

CONCLUSIONS

This study presents us with three ways to reimagine role models in medical education. First, as culturally embedded: having a role model is not as self-evident as it appears in existing role model literature, which is largely based on research conducted in the U.S. Second, as cognitive constructs: the participants engaged in selective imitation, where they did not have one archetypical clinical role model, but rather approach role models as a mosaic of elements from different people. Third, role models carry not only a behavioural but also a symbolical value, the latter of which is particularly important for URiM students because it relies heavier on social comparison.

The development of an educational workshop to reframe and manage professional conflict via a sex and gender lens

Background

Conflict is inevitable in the emergency department, and conflict resolution is an essential skill for emergency providers to master. Effective conflict management can optimize patient care and enhance professional satisfaction. To communicate effectively in high-stress, high-impact situations, sex- and gender-based differences need to be considered.

Methods

Nine resident, fellow, junior, and senior faculty members of the Academy for Women in Academic Emergency Medicine collaborated to design a 4-h workshop. The focus was on professional communication and conflict resolution in emergency medicine (EM), with special attention on how sex and gender can influence these processes.

Results

The final educational workshop utilized a variety of formats focused on communication and effective conflict resolution including: traditional didactics, facilitated small groups with case-based learning, expert panel discussion, and an experiential learning session. The consideration of how sex- and gender-associated factors might contribute additional complexity or challenges to conflictual interactions were interwoven into each session to highlight alternative vantage points.

Conclusions

Effective conflict resolution is an important skill for success in EM. We developed a workshop that went beyond typical communication-based programming to consider how sex- and gender-related factors influence communication and conflict resolution.

Diversity, Equity, and Inclusion Efforts at a Departmental Level: Building a Committee as a Vehicle for Advancing Progress

Academic Health Centers (AHCs) across the nation are experiencing a reawakening to the importance of Diversity, Equity, and Inclusion (DEI). Such work impacts both employees and patients served by healthcare institutions. Yet, for departments without previously existing formal channels for this work, it is not always apparent where to begin. The current manuscript details a process for creating a committee as a vehicle for championing DEI efforts at the department level within an AHC. The authors present a six-step model for forming a DEI Committee and progress monitoring measures to remain accountable to identified objectives. In each step, the authors provide examples of their work with the goal for readers to tailor and apply each step to their own departments' DEI efforts. The current paper also identifies lessons learned with regard to barriers and facilitators of department-level DEI work. Reflections and next steps for DEI work beyond the proposed model are also discussed.

Original Research: Nurses' Experiences with Racial, Ethnic, Cultural, and Religious Discrimination in the Workplace: A Qualitative Study

BACKGROUND

As the health care workforce diversifies, understanding and addressing the lived experiences of health care professionals facing prejudice and discrimination becomes increasingly important. Previous studies have focused on physicians and medical trainees, but there remains a dearth of research exploring nurses' experiences-even though nurses make up the largest sector of the nation's health care workforce.

OBJECTIVE

This qualitative study explored nurses' experiences of personally mediated workplace discrimination based on race, ethnicity, culture, or religion.

METHODS

We conducted in-depth interviews with a convenience sample of 15 RNs at one academic medical center. Using an inductive thematic analysis approach, we identified several themes emerging from RNs' experiences and responses to a discriminatory event ("encounter"). Themes were grouped across three phases: pre-encounter, encounter, and post-encounter.

RESULTS

Participants reported wide-ranging experiences, from insensitive joking to overt exclusion, coming from various people including patients, patients' family members, colleagues, and physicians. For many, discrimination was cumulative: similar encounters occurred outside the workplace as well as within the clinical setting, often repeatedly, and were influenced by the sociopolitical context. Participants reported a variety of responses, including emotional reactions such as shock, fear of retaliation, and frustration at being expected to represent one's identity group. Silence or inaction predominated bystander and supervisor responses. Although the encounters themselves were fleeting, their impact was enduring. Early-career encounters were most challenging, and participants grappled internally with lasting effects for years. Long-term effects included avoidance of perpetrators, disconnection from colleagues and their own professional role, and leaving the workplace.

CONCLUSIONS

The findings illuminate nurses' experiences with racial, ethnic, cultural, and religious discrimination in the workplace. Understanding how such discrimination affects nurses is critical to developing effective responses to encounters, creating safer workplaces, and promoting equity within the profession.

Incongruous identities: Mental distress and burnout disparities in LGBTQ+ health care professional populations

Health care professionals are chronically overworked due to structural workplace demands and institutional challenges [1]. During the COVID-19 pandemic, US biomedical health care professionals experienced additional environmental strain [2]. Health care professionals who occupy socio-politically minoritized identities are more likely to report symptoms of distress and workplace overburden than their counterparts [2]. While minority stress and identity formation theories explain the relationship between socially constructed identity and environmental strain, these theories remain largely unexplored in LGBTQ+ health care professional populations. Furthermore, contemporary investigations into health care professional burnout and mental distress fail to include differential impacts of identity-based stress, particularly within LGBTQ+ groups. This paper proposes a theoretical explanation for differential stress experiences by health care professionals and calls for research to investigate identity congruence as a key aspect of professionalization in medical schools. Health professions researchers need to attend to identity-based stress models to address discriminatory experiences with burnout and mental distress.

White supremacy culture and the assimilation trauma of medical training: ungaslighting the physician burnout discourse

The physician burnout discourse emphasises organisational challenges and personal well-being as primary points of intervention. However, these foci have minimally impacted this worsening public health crisis by failing to address the primary sources of harm: oppression. Organised medicine's whiteness, developed and sustained since the nineteenth century, has moulded training and clinical practice, favouring those who embody its oppressive ideals while punishing those who do not. Here, we reframe physician burnout as the trauma resulting from the forced assimilation into whiteness and the white supremacy culture embedded in medical training's hidden curriculum. We argue that 'ungaslighting' the physician burnout discourse requires exposing the history giving rise to medicine's whiteness and related white supremacy culture, rejecting discourses obscuring their harm, and using bold and radical frameworks to reimagine and transform medical training and practice into a reflective, healing process.

Gender trends in applicants to general surgery residency programs in Canada

BACKGROUND

Surgical disciplines lag behind non-surgical disciplines in attracting female trainees. Female representation of Canadian General Surgeons has not been evaluated in recent years in the literature. The objectives of this study were to assess gender trends in applicants to Canadian General Surgery residency programs and practicing general surgeons and subspecialists.

METHODS

This retrospective cross-sectional study analyzed gender data for residency applicants ranking General Surgery as their first-choice discipline from publicly-available annual Canadian Residency Matching Service (CaRMS) R-1 match reports from 1998 to 2021. Aggregate gender data for practicing female physicians in General Surgery and related subspecialties, including Pediatric Surgery, obtained from annual Canadian Medical Association (CMA) census from 2000 to 2019 was also analysed.

RESULTS

There was a significant increase in the proportion of female applicants from 34% in 1998 to 67% in 2021 (p < 0.001) and of successfully matched candidates from 39% to 68% (p = 0.002) from 1998 to 2021. Success rates between male and female candidates were significantly different in 1998 (p < 0.001), but not in 2021 (p = 0.29). The proportion of practicing female General Surgeons also significantly increased from 10.1% in 2000 to 27.9% in 2019 (p = 0.0013), with variable trends in subspecialties.

CONCLUSION

Gender inequality in General Surgery residency matches has normalized since 1998. Despite females representing more than 40% of applicants and successfully matched candidates to General Surgery since 2008, a gender gap still exists amongst practicing General Surgeons and subspecialists. This suggests the need for further cultural and systemic change to mitigate gender disparities.

TYPE OF STUDY

Original research article, clinical research.

LEVEL OF EVIDENCE

Level III (Retrospective cross-sectional study).

Survey of student mistreatment experienced during the core clinical clerkships

BACKGROUND

The goal of this study was to learn more about the potential impact of medical student mistreatment on patient safety and care.

METHODS

A web-based survey was sent to members of the class of 2021 and 2022 who have completed their core clerkships at a single academic institution. Descriptive statistics were performed to understand how prior and future mistreatment impacted communication among students and team members.

RESULTS

We received 290 of 376 responses (77.1%). 26% of respondents indicated that past mistreatment negatively impacted their communication with other team members. 30% of respondents reported that fear of future mistreatment negatively impacted their communication with other team members.

CONCLUSION

Mistreatment of medical students has many sources and occurs throughout the clinical curriculum. Past and fear of future student mistreatment can negatively impact intrateam communication and therefore negatively impact patient care, with the potential of causing poor patient outcomes.

A cross-sectional study examining perceptions of discriminatory behaviors experienced and witnessed by veterinary students undertaking clinical extra-mural studies

Introduction

Recent research showed that 29% of respondents in a survey of veterinary professionals reported experiencing self-described discrimination in their workplaces. Senior colleagues and clients were responsible for discriminatory behaviors. As part of their training, veterinary students are expected to undertake extra-mural study (EMS) within these same workplaces and are likely to be vulnerable to discrimination from senior colleagues and clients. This study's objectives were to identify and characterize the pattern of perceived discriminatory behaviors (i.e., belief of being treated unfairly) that veterinary students encounter while seeing practice and explore students' attitudes toward discrimination.

Methods

Students at British and Irish veterinary schools who undertook some clinical EMS completed a survey of closed and open questions as part of a cross-sectional study. Demographic data and experiences of discrimination with details of incidents and reporting were collected, alongside respondent attitudes. Quantitative data were analyzed using Pearson's chi-squared analysis to analyse respondents' characteristics and their experiences of discriminatory behaviors and subsequent reporting. Qualitative content analysis was used for open-question data.

Results

Of the 403 respondents, 36.0% had perceived behavior they believed was discriminatory. The most frequent form of discrimination was based on gender (38.0%), followed by ethnicity (15.7%). There were significant associations between respondents' experience of discriminatory behaviors and the following characteristics: age (p = 0.0096), disability (p < 0.00001), race/ethnicity (p < 0.0001), gender/sex (p = 0.018), and LGBTQ+ status (p = 0.001). Supervising veterinarians were the most commonly reported perpetrators of discriminatory behaviors (39.3%) compared with clients (36.4%). Only 13.9% of respondents who experienced discrimination reported the event(s). Respondents with a disability were the least likely to agree with the statement that professional bodies are doing enough to tackle discrimination (p < 0.0001). Most respondents agreed that sexism is still an issue (74.4%), but men were more likely to disagree (p = 0.004). Most respondents felt that ethnic diversity needed to be increased (96.3%).

Discussion

Discriminatory behavior is a problem for students seeing practice, especially those with one or more protected characteristics (as defined by the UK Equality Act 2010). Improved education would need to include perspectives from minority groups to help remove discriminatory behavior from veterinary practice.

Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014-19

The US physician workforce does not reflect the racial and ethnic makeup of the country's population, despite efforts to promote diversity. Becoming a physician requires significant time and financial investment, and populations that are underrepresented in medicine have also been excluded from building wealth. Understanding the differential burden of debt by race and ethnicity may inform strategies to improve workforce diversity. We used 2014-19 data on postgraduate resident trainees from the Association of American Medical Colleges to examine the association between race and ethnicity and debt independent of other demographics and residency characteristics. Black trainees were significantly more likely to have every type of debt than the overall sample and all other racial and ethnic groups (96 percent of Black trainees had any debt versus 83 percent overall; 60 percent had premedical education loans versus 35 percent overall, and 50 percent had consumer debt versus 25 percent overall). American Indian/Alaska Native, Hispanic, and Native Hawaiian/Pacific Islander trainees were more likely to have debt compared with White and Asian trainees. Overall, debt prevalence decreased over time and varied by specialty; however, for Black trainees, debt decreased minimally over time and was stable across specialties. Scholarships, debt relief, and financial guidance should be explored to improve diversity and inclusion in medicine across specialties.

Training satisfaction and well-being among veterinary anaesthesia residents: time for action

OBJECTIVE

To explore the satisfaction and well-being experienced by anaesthesia residents during their training, and to investigate factors that may have influenced their experiences.

STUDY DESIGN

Cross-sectional online anonymous voluntary survey.

SAMPLE POPULATION

A total of 150 (of approximately 600 canvassed) former veterinary anaesthesia residents.

METHODS

Participants were invited to complete an internet-based survey regarding the satisfaction and well-being experienced during their residency. Multiple choice, categorical, dichotomous, Likert-type rating scales and slider questions were used to investigate five domains (demographic, working conditions, educational environment, training satisfaction, well-being). Sampling adequacy, questionnaire reliability and participant responses were investigated by Kaiser-Meyer-Olkin (KMO) indices, Cronbach's α and standard statistical techniques, respectively (p < 0.05).

RESULTS

The questionnaire demonstrated good sampling adequacy (median KMO index 0.74; range 0.51-0.89) and high item 'reliability' (α = 0.82-0.94). Of the 150 responders, (25% participation rate) 62% were satisfied, 14% were neutral and 24% were dissatisfied with their residency training; 60.6% would do the residency again, 39.3% would not or were unsure. Sex and age did not correlate with training satisfaction (p > 0.05). Salary/stipend was considered inadequate by 70% of responders; 66% received no on-call supplement. Greater supervisory input, a good working environment and extra income when on-call were positively correlated with training satisfaction (p < 0.01). The majority (94.6%) of trainees suffered from at least one medical condition during their residency, with fatigue, sleep disturbance or anxiety reported by > 62%.

CONCLUSIONS

Although a quarter of responders were dissatisfied with their residency, several modifiable factors were identified, particularly with respect to supervisors' input, working environment and pay, which could inform improvements for future residency programmes. Most trainees experienced negative health impacts; however, this parallels the general situation in both the medical and veterinary professions, which requires greater attention from the supervisors, trainees and colleges.

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace

BACKGROUND

Unprofessional behaviour undermines organizational trust and negatively affects patient safety, the clinical learning environment, and clinician well-being. Improving professionalism in healthcare organizations requires insight into the frequency, types, sources, and targets of unprofessional behaviour in order to refine organizational programs and strategies to prevent and address unprofessional behaviours.

OBJECTIVE

To investigate the types and frequency of perceived unprofessional behaviours among health care professionals and to identify the sources and targets of these behaviours.

METHODS

Data was collected from 2017-2019 based on a convenience sample survey administered to all participants at the start of a mandatory professionalism course for health care professionals including attending physicians, residents and advanced practice providers (APPs) working at one academic hospital in the United States.

RESULTS

Out of the 388 participants in this study, 63% experienced unprofessional behaviour at least once a month, including failing to respond to calls/pages/requests (44.3%), exclusion from decision-making (43.0%) and blaming behaviour (39.9%). Other monthly experienced subtypes ranged from 31.7% for dismissive behaviour to 4.6% for sexual harassment. Residents were more than twice as likely (OR 2.25, p<0.001)) the targets of unprofessional behaviour compared to attending physicians. Female respondents experienced more discriminating behaviours (OR 2.52, p<0.01). Nurses were identified as the most common source of unprofessional behaviours (28.1%), followed by residents from other departments (21%).

CONCLUSIONS

Unprofessional behaviour was experienced frequently by all groups, mostly inflicted on these groups by those outside of the own discipline or department. Residents were most frequently identified to be the target and nurses the source of the behaviours. This study highlights that unprofessional behaviour is varied, both regarding types of behaviours as well as targets and sources of such behaviours. This data is instrumental in developing training and remediation initiatives attuned to specific professional roles and specific types of professionalism lapses.

Factors Associated with Commercial Sex Behavior among Male College Students Who Engaged in Temporary Heterosexual Behavior in Zhejiang Province, China

Objective

This study explored the characteristics and associated factors of commercial sex behavior among male college students who engaged in temporary heterosexual behaviors in Zhejiang Province, China.

Methods

The participants were male college students with temporary heterosexual behaviors. We developed an online questionnaire to collect information on demographic characteristics, sexual attitudes, sexual behaviors, and HIV/AIDS interventions through stratified cluster sampling. Chi-square (χ ²) tests were performed for the different groups of participants. The occurrence of commercial sex behavior among participants was taken as the dependent variable, and logistic regression was used to analyze the factors associated with the participants' commercial sex behavior.

Results

This study investigated the temporary heterosexual behavior of 424 male college students. Among them were 112 students who reported commercial sex behavior (26.42%), whose average age was 20.25 ± 1.27 years, and whose household registration of Zhejiang Province accounted for 63.39%. The results of the multivariate logistic regression analysis indicated that acceptance of commercial sex behavior (Adjusted (a) OR = 3.53, 95% CI = 1.94~6.40) and feeling at risk of contracting HIV (aOR = 6.44, 95% CI = 2.98~13.94), seeking temporary sexual partners through the Internet (aOR = 2.58, 95% CI = 1.27~5.25), consistently using condoms during sex (aOR = 0.34, 95% CI = 0.16~0.70), or using condoms sometimes/frequently during sex (aOR = 0.30, 95% CI = 0.13~0.68) were independent factors associated with male college students with temporary heterosexual behavior engaging in commercial sex behavior.

Conclusion

Open sexual attitudes, seeking temporary sexual partners through the Internet, high awareness of HIV infection risk, and low condom use are associated factors for male college students engaging in commercial sex behavior. For college students' HIV/AIDS prevention and education interventions, it is necessary to strengthen the prevention of network influence, increase peer education, increase teacher participation in education, enhance college students' risk awareness, advocate for the use of condoms, and promote HIV/AIDS prevention and treatment.

Gender and Race Demographics of Fellowships After General Surgery Training in the United States: A Five-Year Analysis in Applicant and Resident Trends

INTRODUCTION

The gender and minority gap in general surgery residency is narrowing; however, literature lacks comprehensive data regarding the demographics of fellowship programs following general surgery training.

METHODS

Data from 2017 to 2021 for gender, ethnicity, and surgical subspecialty are publicly available from the ERAS database and ACGME yearly data reports. Cochran-Armitage trend tests were used to determine statistical significance in trends for female and minority applicants and trainees.

RESULTS

The overall trend of female applicants to surgical specialties remained stagnant. However, female applicants to vascular surgery increased significantly from 25% to 35% (P = .045). There was no significant increase in female trainees in any surgical specialties evaluated. Furthermore, the overall trend of minority applicants to surgical specialties also remained stagnant, except for pediatric surgery, which showed significantly fewer minority applicants. Despite pediatric surgery having fewer applicants, minority trainees in this specialty increased significantly from 8% to 19% (P = .008).

CONCLUSION

Several current initiatives, such as intentional mentorship, are being reported to promote diverse and equal representation among female and minority applicants and trainees. However, the current overall margin of increase in diversity among surgical specialty applicants and trainees is minimal, indicating that continued efforts are needed to diversify surgical specialty training programs.

Impact of workplace violence on anxiety and sleep disturbances among Egyptian medical residents: a cross-sectional study

BACKGROUND

Workplace violence (WPV) against healthcare workers is a common occurrence worldwide, especially among young physicians and medical residents. This study aimed to explore the negative health impacts of WPV among medical residents in Egypt, and their perception regarding how safe it is to report violence.

PURPOSE

To investigate the prevalence of WPV among medical residents, its possible negative health impacts, specifically on sleep quality and mental health, and the perceived workplace safety climate.

METHODS

This is a cross-sectional analytic study, using a convenience sample through an online questionnaire. An abuse index was calculated, generalized anxiety disorder (GAD) and sleep quality were collected from the reported outcomes.

RESULTS

The study sample included 101 residents (86.1% females). The most common reported form of abuse was verbal abuse, with the most common reported perpetrators being senior staff members (59.4%). About 86% of participants were classified as poor sleepers, while 59.4% had GAD, and there were significant positive correlations between GAD and Global Pittsburgh Sleep Quality Index (PSQI) scores with the abuse index. More than one third (35.6%) of residents reported a very high-risk Psychosocial Safety Climate (PSC) score, and 31.6% of them either strongly agreed or agreed that reporting a sexual harassment claim would be dangerous.

CONCLUSION

Workplace violence is common among Egyptian medical residents, with a significant negative impact on sleep quality and a rising risk of GAD. The promotion of a safe workplace environment is essential in protecting the health and wellbeing of medical residents.

Identifying Student Mistreatment Through Peer-Facilitated Learning Environment Sessions

PROBLEM

Data from the Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ) show persistent high rates of medical student mistreatment, and multiple barriers to student reporting of mistreatment exist. The authors examined whether learning environment sessions (LESs) allow students opportunities to identify and describe patterns of mistreatment missed by other avenues of reporting.

APPROACH

Peer-facilitated LESs were instituted in 2018-2019 at Boston University School of Medicine. The LESs were scheduled once during every third-year core clerkship block. Third- and fourth-year students trained as peer-facilitators led discussions of topics relevant to the student clinical experience using a standardized facilitator guide. Minutes, including details of reported events, were completed during the session and visible to all students participating. These minutes were sent to clerkship leadership and the medical education office for action once student grades were submitted.

OUTCOMES

Summative content analysis was conducted on 44 LES minutes from sessions held in January-November 2019. Reported incidents were categorized into broad categories of negative treatment (NT), negative learning environment (NLE), and positive learning environment (PLE). Sixty-three instances of NT were identified. Of these, 37 fit within the scope of the AAMC GQ mistreatment categories. The remaining 26 instances of NT were classified into 7 novel categories of medical student mistreatment. Instances of NLE were most discussed by students and categorized into 5 subthemes. Examples of PLE were categorized into 4 subthemes, which encompassed 11 descriptors of core qualities of an ideal preceptor or educational environment.

NEXT STEPS

LESs have aided in identifying and describing new patterns of mistreatment. They fulfill a unique role by allowing students to identify, analyze, and report mistreatment in a facilitated and protected space. Formal evaluations of institutional improvement in the learning environment, reduction in medical student mistreatment, and subsequent improvement in AAMC GQ data are needed.

Variation in Research Experiences and Publications During Medical School by Sex and Race and Ethnicity

Importance

Diverse research teams are critical to solving complex health problems and producing high-quality medical research.

Objective

To examine the associations of student sex and racial and ethnic identity with publication rates during medical school.

Design, Setting, and Participants

This cohort study assessed individual-level data of US MD graduates from medical school who matriculated in academic years 2014 to 2015 and 2015 to 2016. Data were obtained from the Association of American Medical Colleges and analyzed from October 2021 to January 2022.

Main Outcomes and Measures

Outcomes of interest included students' self-reported participation in unique research experiences, number of publications, and computed publications per research experience. Poisson regressions were constructed to determine the association of sex and racial and ethnic identity with research outcomes using adjusted rate ratios (aRRs).

Results

Among 31 474 graduates, 15 159 (48.2%) identified as women and 4344 (13.8%) identified as underrepresented in medicine by race and ethnicity (URIM; including American Indian, Alaska Native, Black, Hawaiian Native, Hispanic/Latinx, and Pacific Islander individuals). Students who attended National Institutes of Health (NIH) top 40 research-ranked schools reported higher number of research experiences and publication counts, resulting in a higher publication rate compared with students from non-top 40 schools (median [IQR] 1.60 [1.00-3.00] vs 1.25 [0.50-2.33]; P < .001). Women reported a higher number of research experiences than men but a significantly lower number of publications (top 40 schools: aRR, 0.89; 95% CI, 0.87-0.90; non-top 40 schools: aRR, 0.93; 95% CI, 0.92-0.95). This resulted in a significantly lower publication rate among women (top 40 schools: aRR, 0.85; 95% CI, 0.83-0.86; non-top 40 schools: aRR, 0.91; 95% CI, 0.90-0.92). Compared with White students, Asian students had higher publication rates at both NIH top 40 schools (aRR, 1.10; 95% CI, 1.08-1.12) and non-top 40 schools (aRR, 1.07; 95% CI, 1.05-1.08), while lower publication rates were reported among Black students (top 40 schools: aRR, 0.83; 95% CI, 0.80-0.86; non-top 40 schools: aRR, 0.88; 95% CI, 0.85-0.95) and Hispanic students attending non-top 40 schools (aRR, 0.93; 95% CI, 0.90-0.95).

Conclusions and Relevance

These findings illustrate that inequities in the physician-scientist workforce began early in training and highlight key areas for intervention, such as funding support and mentorship training during undergraduate medical education, that may promote the future success of a diverse physician-scientist workforce.

An investigation of preceptors' perceptions of behavioral elements of “professionalism” among genetic counseling students

Professionalism in health care is a loosely defined but increasingly studied concept. In genetic counseling, "professional development" expectations for entry-level genetic counselors are described in the "Practice-Based Competencies for Genetic Counselors," but the teaching and evaluation of "professionalism" among genetic counseling students is relatively unexplored. This study investigated program leaders' and clinical supervisors' perceptions of professionalism demonstrated by genetic counseling graduate students to learn about their associated strengths and lapses. Members of program leadership and clinical supervisors at Accreditation Council for Genetic Counseling (ACGC) accredited genetic counseling graduate programs in the United States and Canada were surveyed regarding their observations of genetic counseling students for the years 2017-2019 regarding four domains of professional behavior: integrity, accountability/conscientiousness, teamwork, and patient care, with the Merriam-Webster definition of each behavior provided for each domain. Participants also provided open-text descriptions. Descriptive results showed that the 263 participants found all facets of these professional behaviors to be essential. Patient care had the highest importance and was the domain with the most strengths observed among genetic counseling students. Lapses in professional behavior were identified for self-awareness, time management, and thoroughness. Free responses noted that suggestions or strategies for education about professional behavior from ACGC may improve the professional behavior of genetic counseling students and in turn, genetic counselors. Participants voiced the importance of consideration of diverse professional and cultural backgrounds in setting the expectations for professional behavior among genetic counseling students and genetic counselors so that "professionalism" in genetic counseling is not defined through a White lens. Further investigation into challenges that genetic counseling students face regarding professional behavior during their graduate training and strategies for education about these behaviors will aid in the growth and improvement of the training of genetic counselors. Given the sensitive nature of this topic, portions of this discussion may be triggering for some readers.

Build & Belong: A Peer-Based Intervention to Reduce Medical Student Social Isolation

PROBLEM

Medical school can be a socially isolating experience, particularly for students underrepresented in medicine. Social isolation and perceptions of not belonging can negatively impact students' academic performance and well-being. Therefore, interventions are needed to support students and these efforts should be appealing, brief, and low-burden.

INTERVENTION

Guided by evidence-based approaches, we developed the Build & Belong intervention for medical students as a brief peer-to-peer approach that consisted of four components. First, M3 and M4 students wrote reflections on belonging in medical school. Second, M3 and M4 students video recorded messages for M1 and M2 students using their written reflections. Third, M1 and M2 students watched and discussed the videos in small groups. Fourth, the M1 and M2 students wrote letters to future students. Our intervention differs from previous student belonging interventions in the peer delivery of messages.

CONTEXT

The Build & Belong intervention aimed to improve medical students' social belongingness. Using a longitudinal observational study design, the intervention was piloted at a medical school in the Mid-Atlantic United States in 2017-2018. Students completed surveys before and after the intervention. Paired samples tests (t-tests and Wilcoxon) assessed pre- to post-intervention changes in social isolation, social connectedness, and social assurance.

IMPACT

Among 63 medical students, with 25.9% from backgrounds underrepresented in medicine, we assessed follow-up outcomes in 38 students. Social isolation scores significantly decreased from baseline (M = 54.8, SD = 7.06) to follow-up (M = 51.3, SD = 6.67; p < .001). Social isolation changes were evident regardless of sex, although males reported a greater reduction (M Δ = -5.32, p < .001) than females (M Δ = -2.79, p = .014). Black/African American students had the largest reduction in social isolation (M Δ = -7.24, p = .010). Social assurance and connectedness scores did not change significantly between baseline and follow-up. Medical students appeared to resonate with messages delivered by more experienced peers (M3s and M4s), particularly messages that normalized feelings of not belonging and strategies to reduce those feelings.

LESSONS LEARNED

The Build & Belong intervention appears to reduce social isolation scores among medical students. This pilot test of the Build & Belong intervention provides initial evidence of the effectiveness of a brief, low-cost intervention. Build & Belong may provide a scalable strategy to reduce medical students' social isolation. Our peer-based approach is distinct from administrator-led strategies; peers were seen as trusted and reliable sources of information about belonging and ways to overcome the challenges experienced during medical school.

Association of Marginalized Identities With Alpha Omega Alpha Honor Society and Gold Humanism Honor Society Membership Among Medical Students

IMPORTANCE

Disparities in medical student membership in Alpha Omega Alpha (AOA) are well documented. Less is known about Gold Humanism Honor Society (GHHS) membership and it remains unknown how the intersection of different identities is associated with membership in these honor societies.

OBJECTIVE

To examine the association between honor society membership and medical student race and ethnicity, sex, sexual orientation, socioeconomic status, and intersection of identities.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from Association of American Medical Colleges data collection instruments. The study included all students who graduated from Liaison Committee on Medical Education-accredited US medical schools from 2016 to 2019 and completed the Graduation Questionnaire. Data analysis was conducted from January 12 to July 12, 2022.

MAIN OUTCOMES AND MEASURES

Likelihood of AOA and GHHS membership by student race and ethnicity, sex, sexual orientation, childhood family income, and intersection of identities.

RESULTS

The sample of 50 384 individuals comprised 82 (0.2%) American Indian or Alaska Native, 10 601 (21.0%) Asian, 2464 (4.9%) Black, 3291 (6.5%) Hispanic, 25 (0.1%) Native Hawaiian or Pacific Islander, 30 610 (60.8%) White, 2476 (4.9%) multiracial students, and 834 (1.7%) students of other races or ethnicities. Sex and sexual orientation included 25 672 (51.0%) men and 3078 (6.1%) lesbian, gay, and bisexual (LGB). Childhood family income comprised 31 758 (60.0%) individuals with $75 000 per year or greater, 8160 (16.2%) with $50 000 to $74 999 per year, 6864 (13.6%) with $25 000 to $49 999 per year, and 3612 (7.2%) with less than $25 000 per year. The sample included 7303 (14.5%) AOA members only, 4925 (9.8%) GHHS members only, and 2384 (4.7%) members of both societies. In AOA, American Indian or Alaska Native (OR, 0.49; 95% CI, 0.25-0.96), Asian (OR, 0.49; 95% CI, 0.45-0.53), Black (OR, 0.25; 95% CI, 0.20-0.30), Hispanic (OR, 0.53; 95% CI, 0.47-0.59), multiracial (OR, 0.69; 95% CI, 0.62-0.77), and other race and ethnicity (OR, 0.73; 95% CI, 0.60-0.88) were underrepresented compared with White students; LGB students (OR, 0.75; 95% CI, 0.67-0.83) were underrepresented compared with heterosexual students; and childhood family income $50 000 to $74 999 (OR, 0.81; 95% CI, 0.75-0.86), $25 000 to $49 999 (OR, 0.68; 95% CI, 0.62-0.74), and less than $25 000 (OR, 0.60; 95% CI, 0.53-0.69) were underrepresented compared with greater than or equal to $75 000. In GHHS, Asian students (OR, 0.80; 95% CI, 0.73-0.87) were underrepresented compared with White students, female students (OR, 1.55; 95% CI, 1.45-1.65) were overrepresented compared with male students, LGB students (OR, 1.36; 95% CI, 1.23-1.51) were overrepresented compared with heterosexual students, and students with childhood family income $25 000 to $49 999 (OR, 0.85; 95% CI, 0.78-0.94) and less than $25 000 (OR, 0.75; 95% CI, 0.66-0.86) were underrepresented compared with those with greater than or equal to $75 000. Likelihood of AOA, but not GHHS, membership decreased as number of marginalized identities increased.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of US medical students, membership disparities were noted in both AOA and GHHS. However, differences in GHHS existed across fewer identities, sometimes favored the marginalized group, and were not cumulative.

Association of Sociodemographic Characteristics With US Medical Student Attrition

Importance

Diversity in the medical workforce is critical to improve health care access and achieve equity for resource-limited communities. Despite increased efforts to recruit diverse medical trainees, there remains a large chasm between the racial and ethnic and socioeconomic composition of the patient population and that of the physician workforce.

Objective

To analyze student attrition from medical school by sociodemographic identities.

Design, Setting, and Participants

This retrospective cohort study included allopathic doctor of medicine (MD)-only US medical school matriculants in academic years 2014-2015 and 2015-2016. The analysis was performed from July to September 2021.

Main Outcomes and Measures

The main outcome was attrition, defined as withdrawal or dismissal from medical school for any reason. Attrition rate was explored across 3 self-reported marginalized identities: underrepresented in medicine (URiM) race and ethnicity, low income, and underresourced neighborhood status. Logistic regression was assessed for each marginalized identity and intersections across the 3 identities.

Results

Among 33 389 allopathic MD-only medical school matriculants (51.8% male), 938 (2.8%) experienced attrition from medical school within 5 years. Compared with non-Hispanic White students (423 of 18 213 [2.3%]), those without low income (593 of 25 205 [2.3%]), and those who did not grow up in an underresourced neighborhood (661 of 27 487 [2.4%]), students who were URiM (Hispanic [110 of 2096 (5.2%); adjusted odds ratio (aOR), 1.41; 95% CI, 1.13-1.77], non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander [13 of 118 (11.0%); aOR, 3.20; 95% CI, 1.76-5.80], and non-Hispanic Black/African American [120 of 2104 (5.7%); aOR, 1.41; 95% CI, 1.13-1.77]), those who had low income (345 of 8184 [4.2%]; aOR, 1.33; 95% CI, 1.15-1.54), and those from an underresourced neighborhood (277 of 5902 [4.6%]; aOR, 1.35; 95% CI, 1.16-1.58) were more likely to experience attrition from medical school. The rate of attrition from medical school was greatest among students with all 3 marginalized identities (ie, URiM, low income, and from an underresourced neighborhood), with an attrition rate 3.7 times higher than that among students who were not URiM, did not have low income, and were not from an underresourced neighborhood (7.3% [79 of 1086] vs 1.9% [397 of 20 353]; P < .001).

Conclusions and Relevance

This retrospective cohort study demonstrated a significant association of medical student attrition with individual (race and ethnicity and family income) and structural (growing up in an underresourced neighborhood) measures of marginalization. The findings highlight a need to retain students from marginalized groups in medical school.

Review: Structural Racism, Children's Mental Health Service Systems, and Recommendations for Policy and Practice Change

OBJECTIVE

Racism is a public health crisis that impacts on children's mental health, yet mental health service systems are insufficiently focused on addressing racism. Moreover, a focus on interpersonal racism and on individual coping with the impacts of racism has been prioritized over addressing structural racism at the level of the service system and associated institutions. In this paper, we examine strategies to address structural racism via policies affecting children's mental health services.

METHOD

First, we identify and analyze federal and state policies focused on racism and mental health equity. Second, we evaluate areas of focus in these policies and discuss the evidence base informing their implementation. Finally, we provide recommendations for what states, counties, cities, and mental health systems can do to promote antiracist evidence-based practices in children's mental health.

RESULTS

Our analysis highlights gaps and opportunities in the evidence base for policy implementation strategies, including the following: mental health services for youth of color, interventions addressing interpersonal racism and bias in the mental health service system, interventions addressing structural racism, changes to provider licensure and license renewal, and development of the community health workforce.

CONCLUSION

Recommendations are provided both within and across systems to catalyze broader systems transformation.

Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education

PURPOSE

To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments.

METHOD

The authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty.

RESULTS

Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (-0.123 [0.05], P = .021), systems-based practice (-0.179 [0.05], P = .005), practice-based learning and improvement (-0.112 [0.05], P = .032), professionalism (-0.116 [0.06], P = .036), and interpersonal and communication skills (-0.113 [0.06], P = .044). Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty -0.199 [0.06] vs women faculty -0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism.

CONCLUSIONS

Resident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.

Three decades of demographic trends among academic emergency physicians

Purpose

To describe trends in emergency medicine faculty demographics, examining changes in the proportion of historically underrepresented groups including female, Black, and Latinx faculty over time.

Methods

Data from the Association of American Medical Colleges faculty roster (1990-2020) were used to assess the changing demographics of full-time emergency medicine faculty. Descriptive statistics, graphic visualizations, and logistic regression modeling were used to illustrate trends in the proportion of female, Black, and Latinx faculty. Odds ratios (OR) were used to describe the estimated annual rate of change of underrepresented demographic groups.

Results

The number of full-time emergency medicine faculty increased from 214 in 1990 to 5874 in 2020. Female emergency medicine faculty demonstrated increases in representation overall, from 35 (16.36%) in 1990 to 2247 (38.25%) in 2020, suggesting a 3% estimated annual rate of increase (OR 1.03, 95% CI 1.03-1.04) and within each academic rank. A very small positive trend was noted among Latinx faculty (n = 3, 1.40% in 1990 to n = 326, 5.55% in 2020; OR 1.01, 95% CI 1.01-1.02), whereas an even smaller, statistically insignificant increase was observed among Black emergency medicine faculty during the 31-year study period (N = 9, 4.21% in 1990 and N = 266, 4.53% in 2020; OR 1.00, 95% CI 0.99-1.00).

Conclusions

Although female physicians have progressed toward equitable representation among academic emergency medicine faculty, no meaningful progress has been made toward racial parity. The persistent underrepresentation of Black and Latinx physicians in the academic emergency medicine workforce underscores the need for urgent structural changes to address contemporary manifestations of racism in academic medicine and beyond.

A Pilot Study of Sexual and Gender Minority Student Experiences in Application to U.S. Medical Schools

Sexual and gender minority (SGM) students in the United States experience adverse dynamics as undergraduates and as medical students, including discrimination or fear of it, heightened stress, and lower social support. Yet little is known about the experiences of SGM medical school applicants. An original survey distributed via SGM student groups at 10 allopathic medical schools in the Midwest yielded quantitative and qualitative data about disclosure of SGM identities during application, experiences of support and discrimination, and resources used. A majority (61.9%) of respondents (n = 42) withheld SGM identities during primary application, most often due to fear of discrimination. A majority (73.8%) expected little or no support from medical schools when deciding whether to disclose SGM identities. Four (12.9%) of 31 total respondents who at some point disclosed an SGM identity experienced discrimination, and three of five (60.0%) gender minorities who disclosed experienced discrimination. Recommendations are offered in light of results.

Ragging, a Form of University Violence in Sri Lanka-Prevalence, Self-Perceived Health Consequences, Help-Seeking Behavior and Associated Factors

Ragging is an initiation ritual practiced in Sri Lankan universities for generations, although research is scarce. This practice has several adverse consequences such as physical, psychological, and behavioral effects and increased university dropouts. The aim of this study was to investigate the prevalence of different types of ragging: emotional/verbal, physical and sexual ragging, self-perceived health consequences, help-seeking behavior, and factors associated with the experience of ragging. A cross-sectional study was conducted among 623, second- and third-year students from the medical, and technology faculties in Jaffna University. Bivariate associations were assessed using chi-squared tests. Logistic regression was used to evaluate factors associated with any type of ragging. Ragging was experienced by 59% of the students, emotional/verbal ragging being the most common. A total of 54% of students suffered one or more health consequences and mainly sought help from friends and family, with few seeking formal help. Factors associated with any type of ragging were faculty and year of study. This study emphasizes the urgent need to address this public health problem. It is important that there are adequate student support services, planning and implementation of effective interventions, as well as ensuring that existing policies are strengthened, to reduce or eliminate ragging in Sri Lanka.

Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education

BACKGROUND

Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern.

OBJECTIVE

Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity.

DESIGN

Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square.

PARTICIPANTS

A total of 689 IM residents, including 330 women and URiM residents (48%).

MAIN MEASURES

ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F_{(2, 1321)} 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37).

CONCLUSION

Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

Discrimination in an "equal country"-a survey amongst Swedish final-year medical students

BACKGROUND

Discrimination due to gender and ethnicity has been found to be widespread in medicine and healthcare. Swedish and European legislation list seven discrimination grounds (age, sex, ethnicity, religion, sexuality, non-binary gender identity, and disability) which may intersect with each other; yet these have only been sparsely researched. The aim of this study was to assess the extent of discrimination, based on these seven discrimination grounds, amongst final-year medical students in Sweden.

METHODS

A web-based survey, based on the CHERRIES-checklist, was disseminated to course coordinators and program directors in charge of final year medical students at all seven medical schools in Sweden. Quantitative data were analyzed using descriptive statistics, Fisher's exact test, and logistic regression. Free-text answers were analyzed thematically using the "Master Suppression techniques" conceptual framework.

RESULTS

Of the 1298 medical students contacted, 247 (19%) took part in the survey. Almost half (n = 103, 42%) had experienced some form of discrimination, and this difference was statistically significant by gender (p = 0.012), self-perceived ethnicity (p < 0.001), country of birth other than Scandinavia (p < 0.001) and visible religious signs (p = 0.037). The most common type of discrimination was gender-based (in 83% of students who had experienced discrimination), followed by age (48%), and ethnicity (42%). In the logistic regression, women/non-binary gender (p = 0.001, OR 2.44 [95% CI 1.41-4.22]), country of birth not in Scandinavia (p < 0.001, OR 8.05 [2.69-24.03]), non-Caucasian ethnicity (p = 0.04, OR 2.70 [1.39-5.27]), and disability (p = 0.02, OR 13.8 [1.58-12040]) were independently associated with discrimination. Half of those who had experienced religion-based discrimination and nearly one-third of victims of ethnicity-based discrimination reported "large" or "extreme" impact of this. Clinical staff or supervisors were the most common offenders (34%), closely followed by patients and their relatives (30%), with non-Caucasian respondents significantly more likely to experience discrimination by patients (p < 0.001).

CONCLUSIONS

Discrimination appears to be frequent in medical school, even in one of the world's "most equal countries". Discrimination is most commonly gender- or ethnicity-based, with ethnicity- and religion-based discrimination appearing to have the largest impact. Future research should continue to evaluate discrimination from an intersectional perspective, adapted for local contexts and legislations.

Doing the Work-or Not: The Promise and Limitations of Diversity, Equity, and Inclusion in US Medical Schools and Academic Medical Centers

While the number of positions, committees, and projects described as "Diversity, Equity, and Inclusion (DEI)" work has grown rapidly in recent years, there has been little attention to the theory, praxis, or lived experience of this work. In this perspective, we briefly summarize the research and concepts put forth by DEI leaders in higher education more broadly, followed by an analysis of the literature's application to academic medicine. We then discuss the ways in which language obscures the nature of DEI and the necessity of scholarship to evaluate the extensive range of practices, policies, statements, and programs the label is given to.

Experiences of Discrimination, Institutional Responses to Seminal Race Events, and Depressive Symptoms in Black U.S. Medical Students

PURPOSE

To examine the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms among Black medical students.

METHOD

This study collected data from a convenience sample of Black U.S. medical students via an anonymous electronic questionnaire in August 2020 that was distributed through the Student National Medical Association and Organization of Student Representatives listservs and an author's social media accounts. It included questions on demographics, institutional responses to seminal race events, experiences of discrimination, and symptoms of depression. Path models were used to examine the relationship between experiences of discrimination, institutional responses to seminal race events, and depressive symptoms among Black medical students.

RESULTS

Of the 750 students completing the survey, 733 (97.7%) were Black. Experiences of discrimination and a lack of institutional responses to seminal race events were associated with more depressive symptoms (b = 0.19, 95% CI: 0.11, 0.26; P < .001 and b = 0.12, 95% CI: 0.04, 0.20; P = .01). After controlling for gender and clinical diagnosis of depression or anxiety before medical school, there was a relationship between experiences of discrimination and institutional responses to seminal race events such that students who reported more experiences of discrimination were more likely to report that their institution did not respond to seminal race events (b = 0.41, 95% CI: 0.34, 0.48; P < .001). Experiences of discrimination moderated the relationship between institutional responses to seminal race events and depressive symptoms (i.e., the relationship between a lack of institutional responses to seminal race events and depressive symptoms was stronger among students who reported more frequent experiences of discrimination).

CONCLUSIONS

Institutions dedicated to supporting Black medical student wellness must be diligent in cultivating a culture intolerant of discrimination and deft in their responses to seminal race events in the larger culture.

Student-Led Initiatives and Advocacy in Academic Medicine: Empowering the Leaders of Tomorrow

Trainees' value as effective leaders within academic medicine has been increasingly recognized. From their perspective as adult learners who enter medical education from diverse backgrounds, trainees offer significant value to the teaching, learning, and practice of medicine. As such, trainees have developed and led various successful initiatives throughout academic medicine. In this Invited Commentary, 2 medical students with national leadership roles provide their perspectives on how student-led initiatives and advocacy can help push academic medicine forward. The authors first provide an overview of the success of student-led initiatives throughout medical education as evidenced by the Trainee-Authored Letters to the Editor in this issue, highlighting the unique contributions and perspectives of trainees in the development and implementation of new initiatives or ways of thinking. Although trainees add value to many areas in academic medicine, here the authors highlight 4 current areas that align with Association of American Medical Colleges priorities: (1) public health emergencies including the COVID-19 pandemic; (2) equity, inclusion, and diversity; (3) wellness and resilience amongst trainees and health care providers; and (4) recent changes to the United States Medical Licensing Examination and the transition to residency. By sharing their experiences with student-led initiatives within each of these domains, the authors provide lessons learned and discuss successes and obstacles encountered along the way. Overall, there is a critical need for increased engagement of trainees in medical education. Empowering trainees now ensures the academic medicine leaders of tomorrow are prepared to face the challenges that await them.

Emergency care of LGBTQIA+ patients requires more than understanding the acronym

Emergency physicians (EPs) frequently deliver care to members of the LGBTQIA+ community in the emergency department. This community suffers from many health disparities important to understand as part of comprehensive care, and these disparities are infrequently discussed in emergency medicine education. Previous data also suggest a need for broader education to increase the comfort of EPs caring for LGBTQIA+ patients. A group of content experts identified key disparities, opportunities for expanded education, and strategies for more inclusive care of LGBTQIA+ patients.

Applicants' perception of fit to residency programmes in the video-interview era: A large multidisciplinary survey

INTRODUCTION

'Fit' refers to an applicants' perceived compatibility to a residency programme. A variety of structural, identity-related and relational factors contribute to self-assessments of fit. The 2021 residency recruitment cycle in the USA was performed virtually due to the COVID-19 pandemic. Little is known about how video-interviewing may affect residency applicants' ability to gauge fit.

METHODS

A multidisciplinary, anonymous survey was distributed to applicants at a large academic institution between rank order list (ROL) certification deadline and Match Day 2021. Using Likert-type scales, applicants rated factors for importance to 'fit' and their ease of assessment through video-interviewing. Applicants also self-assigned fit scores to the top-ranked programme in their ROL using Likert-type scales with pairs of anchoring statements.

RESULTS

Four hundred seventy-three applicants responded to the survey (25.7% response rate). The three most important factors to applicants for assessment of fit (how much the programme seemed to care, how satisfied residents seem with their programme and how well the residents get along) were also the factors with the greatest discrepancy between importance and ease of assessment through video-interviewing. Diversity-related factors were more important to female applicants compared with males and to non-White applicants compared with White applicants. Furthermore, White male applicants self-assigned higher fit scores compared with other demographic groups.

CONCLUSION

There is a marked discrepancy between the most important factors to applicants for fit and their ability to assess those factors virtually. Minoritised trainees self-assigned lower fit scores to their top-ranked programme, which should raise concern amongst medical educators and highlights the importance of expanding current diversity, equity and inclusion efforts in academic medicine.