Admissions Is Not Enough: The Racial Achievement Gap in Medical Education

Advancing health professions education: a review of holistic admissions and competency-based admissions practices

In this review, we gathered information about competency-based admissions and holistic admissions related to healthcare education to understand current practices better and offer recommendations within the healthcare education field. A literature search was conducted to gather peer-reviewed articles detailing information related to competency-based admissions and holistic admissions that have been implemented in healthcare education, including medical schools, nursing schools, dental schools, and other allied health fields. After screening and the addition of articles through ancestral search, 166 articles were included in this systematic review. The articles were coded for information related to definitions of competency-based admissions and holistic admissions, specific desired competencies, procedures to evaluate these competencies, outcomes of these practices, and the success of admitting well-prepared students using these practices. Results show there is wide variation in established definitions and desired competencies. Similarly, there was some variation in methods for evaluating these competencies with some common practices identified. Lastly, little evidence demonstrates the effectiveness of admitting students who are well-prepared for their programs when competency-based or holistic admissions are employed. There is a need for future research to establish a standard definition for both competency-based admissions and holistic admissions. Desired competencies should be established based on the program's mission and vision statements for what type of students they want to admit. Lastly, future research needs to focus on the long-term outcomes of implementing these practices.

First-Generation Low-Income Individuals in Medicine: A Scoping Review

PURPOSE

This comprehensive scoping review of the medical literature on first-generation low-income (FGLI) individuals in medicine aimed to synthesize the highest levels of evidence to inform medical education stakeholders.

METHOD

Database searches were conducted in Academic Search Premier, Education Research Premier, ERIC, Ovid MEDLINE, Ovid Embase, Professional Development Collection, PubMed, Scopus, Google Scholar, and Web of Science Core Collection from database inception through March 15, 2023. English-language articles on first-generation or low-income individuals in medicine from U.S. medical schools were included. Articles were evaluated for level of evidence and themes chosen.

RESULTS

Database searches resulted in 27,075 citations, 247 of which qualified for data extraction. The articles were classified by evidence level: level I (n = 2), level II (n = 17), level III (n = 90), level IV (n = 78), and level V (n = 60). Publications reported on 9 major outcomes: exam performance (n = 108), medical school performance (n = 63), residency and fellowship performance (n = 7), honor society status (n = 12), leave of absence (n = 9), withdrawal, dismissal, and attrition (n = 20), medical education graduation (n = 37), career choice (n = 109), and intent to practice in disadvantaged and rural communities (n = 60). Compared with their peers, FGLI individuals had lower medical school and standardized exam scores, enrollment in national medical honor societies and multiple degree programs, and graduate medical education performance and higher rates of leaves of absence, incompletion of medical education, pursuing primary care and family medicine specialties, and intent to practice in underserved communities.

CONCLUSIONS

Despite an increase in the number of FGLI individuals in medicine, there remains significant opportunity to improve their inclusion and support. Multi-institutional, prospective, risk-adjusted, observational studies are required to determine how to best support FGLI individuals through all medical career stages.

Factors associated with performance on the emergency medicine qualifying examination

Background

Board certification standards exceed the baseline requirements for state licensure, assuring the public that specialists demonstrate additional clinical skills, knowledge, and professional behavior to provide safe and high-quality specialty care. The objective of this study was to determine what physician factors (e.g., gender, age, race/ethnicity, medical school training, and other factors) were associated with the American Board of Emergency Medicine qualifying examination (QE) performance and pass rates.

Methods

This was a national retrospective, observational, cross-sectional study exploring factors associated with the QE. Subjects were physicians who graduated from accredited emergency medicine (EM) categorical residency programs who took the QE for the first time in 2017, 2018, or 2019. A series of multilevel models was used to examine if physician characteristics were related to score and passing the QE. Relative risks were calculated.

Results

There were 6174 EM graduates, 2118 of whom were women and 588 who were underrepresented in medicine (URiM) physicians. Controlling for other variables, in-training examination (ITE) scores and medical doctor (MD) degrees were positively related to mean QE scores, whereas age, 3-year programs, URiM, and male gender were negatively related to mean QE scores. The QE pass rate was 94%, 95% for non-URiM and 86% for URiM. Results of the full model indicated ITE score, age, URiM, gender, MD degree, and residency program format were significantly related to performance on the QE. In the final model, passing the QE was positively related to ITE scores and negatively related to age and URiM. After other variables were controlled for, the adjusted risk ratio for URiM was 0.94.

Conclusions

Several factors were associated with decreased pass rates on the ABEM QE including ITE scores, older age, and URiM, although the risk ratios were small.

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

Exploring the educational journey: perspectives of ethnic minority GP-trainees in Dutch GP-specialty training - a qualitative interview study

BACKGROUND

Previous research highlights persistent differential attainment by ethnicity in medical education, wherein the perceived inclusiveness significantly influences ethnic minority students' and trainees' outcomes. Biased organizational practices and microaggressions exacerbate the challenges faced by ethnic minorities, leading to lower academic performance and higher dropout rates. Consequently, understanding ethnic minority GP-trainees' experiences and perspectives regarding relevant educational aspects is crucial for addressing these disparities and cultivating a more inclusive environment within medical education.

RESEARCH QUESTION

We aimed to investigate the experiences of minority GP-trainees throughout their educational journey in Dutch GP-specialty training, emphasizing their challenges, sources of support, and suggestions for enhancing their learning environment.

METHOD

We conducted semi-structured, in-depth interviews with minority GP trainees, employing purposive convenience sampling to ensure diversity across multiple dimensions. These included gender, age, ethnicity, social background, migration generation, educational stage, encountered challenges, sources of support, and the GP training institute attended. The analysis involved iterative, open and axial coding, followed by generating, reviewing, and defining themes. For a structured analysis of encountered microaggressions, we adopted Sue's Taxonomy of Microaggressions.

RESULTS

All fourteen ethnic minority interviewees had faced educational barriers stemming from misunderstandings and stereotyping in a predominantly 'white' organization. These barriers impacted various aspects of their education, including professional identity formation, application, admission, assessment procedures, social networks, course content, and expert guidance. Microaggressions permeated throughout their educational journey, hindering their full expression and potential. Their ideal GP-specialty training emphasized uniqueness of all trainees, comprehensive staff engagement in inclusivity, robust diversity, equity, and inclusion (DEI)-policies, individual mentorship, transparent standards, concise language usage in test questions, and bias elimination through mandatory DEI staff training.

CONCLUSION

Ethnic minority GP-trainees in the Netherlands face significant challenges like biased assessment and admission, stereotyped course content, inadequate support networks, and microaggressions, putting them at risk for underperformance outcomes. They emphasize the need for inclusive training with robust DEI-policies to eliminate bias.

From Athlete to Surgeon: Examining Sports and Grit Among General Surgery Residents

OBJECTIVE

The transition of Step 1 to pass/fail has generated concerns over selecting promising candidates. Holistic reviews integrate other proficiencies, including extracurriculars such as sports. Grit - defined as perseverance and passion for long-term goals - has been positively associated with competitive activities and is predictive of academic success. The prevalence and impact of sports participation and its relationship to grit in the general surgery resident population has not been described and was investigated in this study.

DESIGN

Surveys measuring sports participation and grit were distributed after the 2021 ABSITE. Grit was assessed through the short grit scale. Inferential statistics were performed.

SETTING/PARTICIPANTS

General surgery residents in all US training programs who completed the 2021 ABSITE.

RESULTS

Of 5468 respondents (response rate 59.6%), 2,548 (46.7%) were female, 917 (17.4%) URiM, 2171 (39.8%) married, and 1,069 (19.6%) parents. About 4284 (83.8%) residents reported being involved in competitive sports. Grit was higher in residents with a competitive sports history (3.67 ± 0.58 versus 3.60 ± 0.61, p = 0.0022). Greater time commitment and being part of a team was positively correlated to grit (both p < 0.0001). Individuals that self-identified as underrepresented in medicine (URiM) had higher grit (3.71 ± 0.59 versus 3.65 ± 0.58 for non-URiM, p < 0.0001) as did female (p = 0.0016), married residents (p < 0.0001), and parents (p < 0.0001). Being an athlete was associated with significantly higher grit for nearly all demographic subgroups, including URiM (p = 0.0068), married (p = 0.0175), and parents (p = 0.0487).

CONCLUSIONS

Higher grit was found in athletes and marginalized groups including females, URiM, and residents that were married or parents. Our data suggests that recruiting applicants of diverse backgrounds and experiences will result in a grittier cohort; a group potentially equipped to weather the arduous surgical residency training path. Recruiting residents with characteristics associated with higher grit can potentially impact diversity of the surgical workforce.

Burnout, Exhaustion, Experiences of Discrimination, and Stress Among Underrepresented and First-Generation College Students in Graduate Health Profession Education

OBJECTIVES

Mental health disorders are increasing among health profession students. Compounding this, students from underrepresented backgrounds may face additional stressors and challenges. The aims of this study were to: (1) assess the extent to which burnout, exhaustion, experiences of discrimination, and stress exist among students in dentistry, nursing, occupational therapy, pharmacy, and physical therapist professional education programs; (2) determine if there are significant differences by key demographic characteristics (those who are first-generation college students [FGCSs], a member of an underrepresented minority [URM] group, or both); and (3) highlight strategies and solutions to alleviate these challenges identified by students.

METHODS

Cross-sectional survey using a mix of question types of a sample of graduate students from dentistry, nursing, occupational therapy, pharmacy, and physical therapy programs from February to June 2020. Utilizing the Maslach Burnout Inventory Student Survey and campus climate and stress survey, mean subscale scores were calculated for the following outcomes of interest: MBI-SS burnout, dimensions of stress, and observed racism. Logistic regressions examined student factors that may help explain these outcomes. Content analysis examined participants' responses to open-ended questions.

RESULTS

There were 611 individuals who completed all survey questions. FGCSs were significantly more likely than non-FGCSs to report exhaustion (adjusted odds ratio [aOR]: 1.50; 95% CI = 1.04-2.16), family stress (aOR: 3.11; 95% CI = 2.13-4.55), and financial stress (aOR: 1.74; 95% CI = 1.21-2.50). URM students reported not feeling supported in their program and mentioned needing additional support, particularly for well-being, from staff and faculty.

CONCLUSION

Findings from this study are consistent with literature that FGCSs experience additional stressors that may lead to burnout and exhaustion. URM students reported not feeling supported in their programs. This study's findings point to the need for leadership and faculty of health professional schools to implement or strengthen current policies, practices, and strategies that support URM students and FGCSs.

IMPACT

Research demonstrates that a diverse student body and faculty enhances the educational experience for health professional students, and that diversity strengthens the learning environment and improves learning outcomes, preparing students to care for an increasingly diverse population. However, this study finds that students from underrepresented backgrounds may still experience more burnout, exhaustion, discrimination, and stress than their peers. Programs and policies to support URM students and FGCSs throughout their academic careers can help improve graduation and retention rates, leading to improved workforce diversity.

"The faculty was really hearing what I had to say and really validating who I was": Learning from validation theory to support students of colour in undergraduate medical education

BACKGROUND

Medical students of colour face numerous challenges during their undergraduate training period, reflecting the harmful norms and cultures in the learning context of medical school. Despite negative experiences for students of colour in medicine, there are episodes of support and encouragement that come from faculty or staff. This asset-based qualitative study uses Rendón's Validation Theory to illuminate specific ways faculty at a community-based medical college support medical students of colour, thereby challenging structural injustices in medical school.

METHODS

This study is grounded in a humanising and asset-based perspective, where participants are viewed as legitimate knowers from whom researchers can learn. Twenty-four medical students of colour and 14 faculty identified by students as supportive participated in five focus groups where participants shared how they felt validated and supported during their undergraduate medical school experiences. Inductive open-coding followed by deductive thematic coding using Validation Theory-a theory that describes how external validation is a necessary component of fostering students' personal and academic drive-and literature about the context of medical school informed the three findings.

FINDINGS

Three major themes provide examples of ways faculty validated students. First, participants indicated the importance of acknowledging identities and experiences to understand the socio, historical and cultural context of learning. Second, participants implored the value of giving praise and offering encouragement to work against professional expectations. Finally, participants shared the intimacy of fostering personal relationships to reduce hierarchies.

CONCLUSION

This study offers concrete guidance on teaching practices faculty can use to support students of colour. As medical schools may seek to move toward a more student-centred approach, promoting feelings of validation for students of colour can be a key practice in teaching and learning to ensure support for medical students throughout their medical school journey.

Are Pre-clerkship Remediation, Grading, and Reporting Practices Equitable in the U.S.? A National Survey

Phenomenon: With the proliferation of pass/fail grading practices in the pre-clerkship phase of undergraduate medical education, questions arise about the transparency and variability of grading and grade reporting practices, raising issues of equity in assessment, particularly regarding residency matching. The purpose of this survey was to determine the remediation and academic performance reporting practices of United States (U.S.) allopathic medical schools in the pre-clerkship phase of their curricula. Approach: After an extensive literature search and feedback from curriculum deans and learning experts, we developed a survey that we sent in the Spring of 2022 to pre-clerkship curriculum officials at all 154 accredited U.S. allopathic medical schools. It addressed curriculum content and structure; pre-clerkship remediation (e.g., course retakes) and reporting (e.g., permanency of transcript notation) practices; documentation and reporting of nonacademic competencies; and participant opinions and recommendations regarding reporting, transparency, and equity. We generated descriptive statistics and did manifest coding of open-ended responses. Findings: We had a response rate of 40% (62/155), with over 71% indicating mainly organ systems-based curricula. Depending on the situation, there were a wide range of remediation approaches for single- and multiple-course failures, including tutoring or learning support, re-exams, and referrals to a promotion board. Professionalism concerns were a top priority to report to residency directors, with significant variability in respondent opinions and practices in reporting remedial activities. Respondents were concerned about equity, both in terms of flexible grading practices and transparency of reporting practices. Insights: The variability in reporting practices across schools, while allowing holistic and individualized approaches to academic support, also creates potential inequities. More work is needed to understand how different reporting practices across institutions may disadvantage marginalized and minoritized student groups at different points in their preparation.

Promoting diversity through exploring and addressing "achievement/opportunity gap" in nursing education: A call to action

Promoting diversity, equity, inclusion, and belonging in nursing education is a contemporary issue. The purpose of this paper is to iterate a call to action for exploring and addressing achievement/opportunity gap in nursing education and propose strategies to address this gap in order to advance diversity, equity, inclusion, and belonging in educational institutions. Achievement/opportunity gap is an academic performance difference among students based on their socioeconomic status, age, race, ethnicity, and other demographic and sociocultural variables, and can lead to lack of career readiness among students. Four strategies are offered to address the achievement/opportunity gap in nursing education which includes a) explicit exploration of the gap to gather baseline information, b) taking an intersectional approach to examine differences in learning styles, beliefs, values, and learning needs of underrepresented and minority student populations, c) offering extensive co-designed preparatory programs to students who may be more prone to encounter this gap, and d) creating support communities for students to foster their academic performance.

Towards inclusive learning environments in post-graduate medical education: stakeholder-driven strategies in Dutch GP-specialty training

BACKGROUND

A recent study found that ethnic minority General Practice (GP)-trainees receive more negative assessments than their majority peers. Previous qualitative research suggested that learning climate-related factors play a pivotal role in unequal opportunities for trainees in post-graduate medical settings, indicating that insufficient inclusivity had put minority students at risk of failure and dropout.

STUDY OBJECTIVES

We aimed to develop broadly supported strategies for an inclusive learning climate in Dutch GP-specialty training.

METHODS

We employed Participatory Action Research (PAR)-methods, incorporating Participatory Learning and Action (PLA)-techniques to ensure equal voices for all stakeholders in shaping Diversity, Equity, and Inclusion (DEI)-strategies for GP-specialty training. Our approach engaged stakeholders within two pilot GP-specialty training institutes across diverse roles, including management, support staff, in-faculty teachers, in-clinic supervisors, and trainees, representing ethnic minorities and the majority population. Purposeful convenience sampling formed stakeholder- and co-reader groups in two Dutch GP-specialty training institutes. Stakeholder discussion sessions were based on experiences and literature, including two relevant frameworks, and explored perspectives on the dynamics of potential ethnic minority trainees' disadvantages and opportunities for inclusive strategies. A co-reader group commented on discussion outcomes. Consequently, a management group prioritized suggested strategies based on expected feasibility and compatibility.

RESULTS

Input from twelve stakeholder group sessions and thirteen co-readers led to implementation guidance for seven inclusive learning environment strategies, of which the management group prioritized three: • Provide DEI-relevant training programs to all GP-specialty training stakeholders; • Appoint DEI ambassadors in all layers of GP-specialty training; • Give a significant voice to minority GP-trainees in their education.

CONCLUSION

The study's participatory approach engaged representatives of all GP-specialty training stakeholders and identified seven inclusive learning climate strategies, of which three were prioritized for implementation in two training institutions.

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

Racial and Ethnic Disparities in Situational Judgment Testing Among Applicants to an Anesthesiology Residency Program

Background The Computer-Based Assessment for Sampling Personal Characteristics (CASPer) is a situational judgment test (SJT) that assesses noncognitive skills like professionalism, communication, and empathy. There are no reports of the effects of race/ethnicity and sex on CASPer scores among residency applicants. Objective We examined the effects of race/ethnicity, sex, and United States vs international medical school attendance on CASPer performance. Methods Our anesthesiology residency program required all applicants for the 2021-2022 Match cycle to complete an online video and text-based SJT (CASPer). We compared these results, reported as z-scores, with self-identified race/ethnicity, sex, United States vs international medical school attendance, and United States Medical Licensing Examination (USMLE) Step 1 scores. Results Of the 1245 applicants who completed CASPer, 783 identified as male. The racial/ethnic distribution was 512 White, 412 Asian, 106 Black, 126 Hispanic, and 89 Other/No Answer. CASPer z-scores did not differ by sex. White candidates scored higher than Black (0.18 vs -0.57, P<.001) and Hispanic (0.18 vs -0.52, P<.001) candidates. Applicants attending US medical schools scored higher than those attending international medical schools (z-scores: 0.15 vs -0.68, P<.001). There was no correlation between CASPer z-scores and USMLE Step 1 scores. Conclusions Our results suggest that CASPer scores favor White applicants over Black and Hispanic ones and applicants attending US medical schools over those attending international medical schools.

Sociodemographic disadvantage in the burden of stress and academic performance in medical school: implications for diversity in medicine

BACKGROUND

Nontraditional students bring to medicine inherent characteristics and perspectives that enrich the learning environment and contribute to expanding diversity in medicine. However, research has shown that these students, by virtue of their sociodemographic backgrounds, face unique challenges in medical education, which ultimately place them at a disadvantage compared to their peers. The purpose of this study is to explore relationships between sociodemographic characteristics, stress, and academic performance, in the context of outcomes that may be undermining efforts to diversify the physician workforce.

METHODS

Using a retrospective observational cohort methodology, we examined institutional and USMLE exam performance data in conjunction with Perceived Stress Scale-4 survey results from six cohorts of students at Kirk Kerkorian School of Medicine at UNLV (n = 358). Using independent samples t-test, mean stress and academic performance were compared between four sociodemographic groups: first-generation college students, underrepresented in medicine (URM), socioeconomically disadvantaged, and age 30 + at matriculation. Results were considered significant where P ≤ .05.

RESULTS

First-generation college students had significantly higher stress at the end of third year clerkships (mean 7.8 vs. 6.8, P* = .03). URM students had significantly lower scores on preclinical exams (mean 81.37 vs. 83.07, P* = .02). The students who were age 30 + at matriculation had significantly lower exam scores on all academic performance measures.

CONCLUSION

Our results echo historic trends in academic performance for racial and ethnic minority students, and we present recent evidence of academic performance disparities based on age at matriculation. Residency program directors continue to use test scores as a primary metric to screen applicants and thus, poor academic performance has profound consequences on career trajectory. Finally, significantly higher stress in the first-generation students may be evidence of underlying psychological distress. Expanding the sociodemographic diversity among physicians, and by extension, medical students, has long been recognized as fundamental to addressing inequities in healthcare. However, results from our study suggest that aspects of medical education are unfavorable and disadvantageous for first-generation, URM, and older medical students. A deeper understanding of the interplay between sociodemographic characteristics and success in medical school is paramount as we pursue diversity in medicine.

Underrepresented Applicants Post-USMLE Pass/Fail: A National Survey of Competitive Residency Directors

Objective

To report the selection criteria important to residency program directors (PDs) and whether they believe pass/fail scoring will impact underrepresented in medicine (URM), International Medical Graduate (IMG), or osteopathic (DO) residency applicants after the United States Medical Licensing Examination (USMLE) changed Step 1 score reporting to pass/fail in January 2022.

Methods

A Qualtrics survey was sent between August 2022 and January 2023 to 1141 US PDs from specialties with traditionally low residency selection rates: dermatology, ophthalmology, otolaryngology, orthopedic surgery, neurosurgery, interventional radiology, diagnostic radiology, radiation oncology, thoracic surgery, vascular surgery, plastic surgery, and urology. Contact information was obtained from AMA, FRIEDA, or program websites.

Results

We received 433 responses (38%). When asked to anticipate the difficulty student groups will face matching into their specialty, PDs reported: for URM, 24.0% increased, 46.0% unchanged, and 30.0% decreased; for DO, 49.19% increased, 44.58% unchanged, and 6.23% decreased and for IMG, 56.35% increased, 39.72% unchanged, and 3.93% decreased. When asked to rank the most important selection factors, the top two responses were Step 2 CK score and away rotation participation at their site.

Conclusion

PDs overwhelmingly believed residency selection difficulty would either increase or remain unchanged for DO (93.77%) and IMG (96.07%). In contrast, 76.0% reported difficulty for URM students would either decrease or remain unchanged. PDs ranked Step 2 CK score and away rotation participation as the most important selection factors. Despite PDs' belief that the Step 1 pass/fail scoring system may mitigate one barrier for URM students, emphasis on Step 2 CK and away rotations place additional barriers.

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.

Perceptual Barriers to Becoming a Plastic Surgeon among Underrepresented Medical Students

Background

The field of plastic surgery has experienced difficulty increasing diversity among trainees, despite significant efforts. Barriers to recruitment of underrepresented in medicine (URM) students are poorly understood. This study assesses URM students' exposure to plastic surgery, access to mentors and research opportunities, and the importance of diversity in the field.

Methods

A survey was designed and distributed to members of the Student National Medical Association over 3 months. Survey data were collected using Qualtrics and descriptive statistics, and logistical regressions were performed using SAS.

Results

Of the 136 respondents, 75.0% identified as Black (n = 102/136), and 57.4% (n = 66/115) reported a plastic surgery program at their home institution. Of the total respondents, 97.7% (n = 127/130) were concerned about racial representation in plastic surgery, and 44.9% (n = 53/114) would be more likely to apply if there were better URM representation. Most respondents disagreed that there was local (73.4%, n = 58/79) or national (79.2%, n = 57/72) interest in URM recruitment. Students whose plastic surgery programs had outreach initiatives were more likely to have attending (OR 11.7, P < 0.05) or resident mentors (OR 3.0 P < 0.05) and access to research opportunities (OR 4.3, P < 0.05).

Conclusions

URM students feel there is an evident lack of interest in recruiting URM applicants in plastic surgery. Programs with outreach initiatives are more likely to provide URM students access to mentorship and research opportunities, allowing students to make informed decisions about pursuing plastic surgery.

Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Peripheral artery disease (PAD) affects 200 million individuals worldwide. In the United States, certain demographic groups experience a disproportionately higher prevalence and clinical effect of PAD. The social and clinical effect of PAD includes higher rates of individual disability, depression, minor and major limb amputation along with cardiovascular and cerebrovascular events. The reasons behind the inequitable burden of PAD and inequitable delivery of care are both multifactorial and complex in nature, including systemic and structural inequity that exists within our society. Herein, we present an overview statement of the myriad variables that contribute to PAD disparities and conclude with a summary of potential novel solutions.

Factors and barriers that influence the matriculation of underrepresented students in medicine

Despite many initiatives over more than 4 decades, the diversity of United States physicians still does not reflect the diversity of the United States population. The present study undertakes a literature review of the last 30 years to investigate barriers and protective factors underrepresented college students encounter as applicants for medical school. Known barriers that influence matriculation into medical school were analyzed such as academic metrics and test scores. Additionally, elements that are less well studied were investigated such as factors perceived as barriers by underrepresented applicants in addition to protective factors that allow them to persist in their journey in the face of difficulties and adversity.

Conflict resolution styles and skills and variation among medical students

BACKGROUND

Conflict is inevitable on healthcare teams, yet few professional school curricula teach or assess conflict resolution skills. Little is known about the variation in conflict resolution styles across medical students and how these styles might impact conflict resolution skills.

METHODS

This is a prospective, single blinded, group randomized quasi experimental trial to assess the impact of knowing one's own conflict resolution style on conflict resolution skills in a simulated encounter. Graduating medical students completed a mandatory conflict resolution session with standardized patients acting as nurses during a transition to residency course. Coaches reviewed videotapes of the simulation, focusing on students' skills with negotiation and emotional intelligence. Retrospectively, we assessed the impact of the students knowing their conflict resolution style prior to simulation, student gender, race, and intended field of practice on conflict resolution skills as judged by coaches.

RESULTS

One hundred and eight students completed the simulated conflict session. Sixty-seven students completed the TKI before the simulated patient (SP) encounter and 41 after. The most common conflict resolution style was accommodating (n = 40). Knowing one's conflict resolution style in advance of the simulation and one's identified race/ethnicity did not impact skill as assessed by faculty coaches. Students pursuing diagnosis-based specialties had higher negotiation (p = 0.04) and emotional quotient (p = 0.006) scores than those pursuing procedural specialties. Females had higher emotional quotient scores (p = 0.02).

CONCLUSIONS

Conflict resolution styles vary among medical students. Male gender and future practice in a procedural specialty impacted conflict resolution skills but knowing conflict resolution style did not.

Effects of race and test preparation resources on standardized test scores, a pilot study

BACKGROUND

Little research exists on the relationship between pre-examination resources, race, and standardized test outcomes. This study aimed to determine the effect of test preparation resources and race on test scores.

METHODS

We surveyed medical students at an allopathic institution on the use of test preparation materials and their test scores. Students were grouped by self-identified race. Underrepresented in Medicine (URiM) students were defined as Black/African American (AA), Hispanic/Latino (HL), Native American (NA) and multiple races. Univariate analysis and linear regression were used for statistical analysis.

RESULTS

192 students completed the survey (response rate = 33%). URiM students reported more MCAT attempts than other students. No differences between scores existed between races. There was no association between scores and the use of test preparation resources.

CONCLUSIONS

We found that URiM students took the MCAT more times than their peers; however, we found no racial/ethnic differences in examination preparation resources or scores.

The Validity of MCAT Scores in Predicting Students' Performance and Progress in Medical School: Results From a Multisite Study

PURPOSE

This is the first multisite investigation of the validity of scores from the current version of the Medical College Admission Test (MCAT) in clerkship and licensure contexts. It examined the predictive validity of MCAT scores and undergraduate grade point averages (UGPAs) for performance in preclerkship and clerkship courses and on the United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge examinations. It also studied students' progress in medical school.

METHOD

Researchers examined data from 17 U.S. and Canadian MD-granting medical schools for 2016 and 2017 entrants who volunteered for the research and applied with scores from the current MCAT exam. They also examined data for all U.S. medical schools for 2016 and 2017 entrants to regular-MD programs who applied with scores from the current exam. Researchers conducted linear and logistic regression analyses to determine whether MCAT total scores added value beyond UGPAs in predicting medical students' performance and progress. Importantly, they examined the comparability of prediction by sex, race and ethnicity, and socioeconomic status.

RESULTS

Researchers reported medium to large correlations between MCAT total scores and medical student outcomes. Correlations between total UGPAs and medical student outcomes were similar but slightly lower. When MCAT scores and UGPAs were used together, they predicted student performance and progress better than either alone. Despite differences in average MCAT scores and UGPAs between students who self-identified as White or Asian and those from underrepresented racial and ethnic groups, predictive validity results were comparable. The same was true for students from different socioeconomic backgrounds, and for males and females.

CONCLUSIONS

These data demonstrate that MCAT scores add value to the prediction of medical student performance and progress and that applicants from different backgrounds who enter medical school with similar ranges of MCAT scores and UGPAs perform similarly in the curriculum.

A disturbing trend: An analysis of the decline in surgical critical care (SCC) fellowship training of Black and Hispanic surgeons

BACKGROUND

Underrepresented minorities in medicine (URiM) are disproportionally represented in surgery training programs. Rates of URiM applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiM disparities would persist into Surgical Critical Care (SCC) fellowship applicants, matriculants and graduates.

METHODS

We performed a retrospective analysis of SCC applicants, matriculants and graduates from 2005-2020 using the Graduate Medical Education (GME) resident survey and analyzed applicant characteristics using the Surgical critical care and Acute care surgery Fellowship Application Service (SAFAS) from 2018-2020. The data were stratified by race/ethnicity and gender. Indicator variables were created for Asian, Hispanic, White and Black trainees. Yearly proportions for each race/ethnicity and gender categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and gender proportion as the dependent variables and year as the explanatory variable.

RESULTS

From 2005-2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased.

CONCLUSIONS

Disparities in URiM representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiM in SCC training are warranted.

LEVEL OF EVIDENCE

Level IV - Therapeutic/Care Management.

Current Views on the New United States Medical Licensing Examination Step 1 Pass/Fail Format: A Review of the Literature

INTRODUCTION

Residency programs have historically used numerical Step 1 scores to screen applicants, making it a career-defining, high-stakes examination. Step 1 scores will be reported as pass/fail starting in January 2022, fundamentally reshaping the residency application review process. This review aimed to identify opinions of physicians and medical students about the new format, identify arguments in support of or against the change, and determine the implications of this change on the residency selection process.

METHODS

A comprehensive PubMed review was performed in May 2021 to identify articles that discussed the new Step 1 format. Non-English and duplicate articles were excluded. Data collected from each article included publication year, specialty, subjects, and key findings.

RESULTS

A total of 81 articles were included, 26 of which discussed the impact of the new format within surgical fields (32.1%). Remaining articles discussed the implications within the medical community as a whole (n = 33, 40.7%) and nonsurgical fields (n = 22, 27.2%). Studies suggest Program Directors will rely on Step 2 Clinical Knowledge (CK) scores, medical school reputation, applicant familiarity, Dean's letters, recommendation letters, and research in lieu of numerical Step 1 scores. In addition, concerns have been raised that the new format will disadvantage international, osteopathic, and minority applicants while increasing stress surrounding Step 2 CK.

CONCLUSIONS

Within the medical community, there are concerns that Step 2 CK will be used to substitute Step 1 and that resident diversity will diminish due to the new Step 1 format. Holistic candidate consideration will be increasingly important.

Racial and Socioeconomic Disparities in Patients With Meningioma: A Retrospective Cohort Study

BACKGROUND

Meningiomas are the most common intracranial neoplasms. Although genomic analysis has helped elucidate differences in survival, there is evidence that racial disparities may influence outcomes. African Americans have a higher incidence of meningiomas and poorer survival outcomes. The etiology of these disparities remains unclear, but may include a combination of pathophysiology and other factors.

OBJECTIVE

To determine factors that contribute to different clinical outcomes in racial populations.

METHODS

We retrospectively reviewed 305 patients who underwent resection for meningiomas at a single tertiary care facility. We used descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses to study clinical, radiographical, and histopathological differences.

RESULTS

Minority patients were more likely to present through the emergency department than an outpatient clinic (P < .0001). They were more likely to present with more advanced clinical symptoms with lower Karnofsky Performance scores, more frequently had peritumoral edema (P = .0031), and experienced longer postoperative stays in the hospital (P = .0053), and African-American patients had higher hospitalization costs (P = .046) and were more likely to be publicly insured. Extent of resection was an independent predictor of recurrence freedom (P = .039). Presentation in clinic setting trended toward an association with recurrence-free survival (P = .055). We observed no significant difference in gross total resection rates, postoperative recurrence, or recurrence-free survival.

CONCLUSION

Minority patients are more likely to present with severe symptoms, require longer perioperative hospitalization, and generate higher hospitalization costs. This may be due to socioeconomic factors that affect access to health care. Targeting barriers to access, especially to subspecialty care, may facilitate more appropriate and timely diagnosis, thereby improving patient care and outcomes.

An Initiative to Increase Residency Program Diversity

A physician workforce that reflects the patient population is associated with improved patient outcomes and promotes health equity. Notwithstanding, racial and ethnic disparities persist within US medical schools, making some individuals underrepresented in medicine (URM). We sought to increase the percentage of URM residents who matched into our pediatric residency programs from a baseline of 5% to 35% to achieve demographic parity with our patients. We developed a multifaceted approach using multiple iterative tests of change, with the primary strategy being increased visibility of URM trainees and faculty to residency applicants. Strategies included applicant interviews with URM faculty, interview dinners with URM residents, visibility at academic conferences for URM trainees, development of targeted marketing materials, and a visiting student program supported by networking with URM residents. The primary outcome measure was the percentage of matched residents in the categorical pediatrics, child neurology, and medical genetics training programs who identified as URM. The percentage of URM residents increased to 16% (6 of 37) in 2018, 26% (11 of 43) in 2019, 19% (8 of 43) in 2020, and 21% (9 of 43) in 2021 (a four-year average of 22% URM residents; P = .0002). This progress toward a more representative residency program was met by challenges, such as pipeline concerns, the minority tax, and recruitment during a pandemic. We were able to implement small, low-resource strategies that had a large cumulative impact and could be implemented in other residency programs. Specific tactics and challenges encountered are discussed in this special article.

How good are medical students at communicating risk? An implementation study at three German medical schools

OBJECTIVE

To assess the objective and subjective risk communication skills of medical students in three universities in Germany METHODS: We developed a risk communication skills Objective Structured Clinical Examination (OSCE) station and implemented it in three medical schools in Germany. 596 students contributed data to a risk communication checklist and a risk communication self-assessment. Multiple linear regression models were used to identify factors associated with the risk communication OSCE performance.

RESULTS

Participants in our study achieved on average 73.5% of the total risk communication skills score, which did not differ between locations (F(2-595) = 1.96; p = 0.142). The mean objective performance of students who assessed their skills as poor was significantly worse than the performance of students who assessed their skills as good (t(520) = -5.01, p < 0.001). The risk communication skills score was associated with native language but not with gender nor General Point Average (p < 0.001).

CONCLUSIONS

Medical students demonstrated acceptable risk communication skills scores and were able to self-assess their performance. However, selected communication techniques should be re-emphasised in the undergraduate medical curriculum.

PRACTICE IMPLICATIONS

Our research identified shortcomings in particular subgroups that can be addressed through tailored curriculum interventions.

Challenging the deficit discourse in medical schools through reverse mentoring-using discourse analysis to explore staff perceptions of under-represented medical students

INTRODUCTION

Despite the increasing diversity of UK medical students, students from low-socioeconomic backgrounds, some minority groups and members of communities with protected identities remain under-represented in medicine. In trying to ascertain why this under-representation persists, literature focuses on the barriers and challenges faced by under-represented students as opposed to the institution's responsibility to remove or mitigate these obstacles. One UK University created a reverse mentoring scheme enabling students to mentor senior members of the medical faculty to help them understand the perspectives and experiences of students from minority backgrounds. This paper explores whether changes in staff perceptions of under-represented students resulted from engaging with reverse mentoring.

METHODS

This qualitative study explored the impact of the reverse mentoring scheme. Staff mentees were required to write a narrative text about the Higher Education journey of an under-represented medical student before and after the reverse mentoring intervention. These texts were compared using discourse analysis to identify shifts in language use that demonstrated a change in perceptions.

RESULTS

The key themes from five senior staff members indicate a positive change in staff characterisation of the students and an acceptance of institutional responsibility for challenges faced. Initial texts revealed a superficial understanding of the student journey that focused on individual deficit but had fairy tale endings depicting the medical school as benevolent. The follow-up texts revealed a deeper understanding reflected by the portrayal of students as capable agents and containing pragmatic endings acknowledging the responsibility of the medical school.

CONCLUSION

These findings highlight how removed senior staff can be from the reality of the student experience and that engaging with reverse mentoring helps to raise awareness and challenges the students face. This suggests a route for constructive change in medical schools and endorses the benefits of facilitating open discussion around educational inequity.

Underrepresented in medicine in graduate medical education: Historical trends, bias, and recruitment practices

Health inequities disproportionately impact children of color in the United States. Research demonstrates that a diverse physician workforce that reflects the demographic profile of the United States population has been associated with better health outcomes and physicians of color are more likely to work in communities that are medically underserved. Therefore, a key driver to reducing health inequities is recruiting a physician workforce that reflects the racial/ethnic composition of the population. Although efforts on increasing UIM applicants and matriculants into medical school and more recently, graduate medical education (GME) programs have shown some small successes, there has still not been significant change in decades. This narrative review examined the historical trends and current landscape of recruitment in GME to better understand the barriers and facilitators that continue to exist and identify successful interventions that might serve as a model to support recruitment of UIM applicants. There is evidence for racial disparities and bias in traditional residency selection metrics (USMLE, Clerkship Evaluations, MSPE, AOA status, etc.) and a need for more holistic recruitment strategies. Along with implementing new holistic recruitment practices, there is a need for ongoing research and collaboration to study inclusive and equitable learning environments and assessments that will eliminate racial disparities in educational outcomes. Additionally, there must be better longitudinal data utilization and transparency across Electronic Residency Application Services (ERAS) and National Resident Matching Program (NRMP) for accountability and tracking of interventions.

US Medical Licensing Exam Performance and American Board of Surgery Qualifying and Certifying Examinations

BACKGROUND

Program directors use United States Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022.

STUDY DESIGN

American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate.

RESULTS

The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively.

CONCLUSIONS

USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.

Trends in Race/Ethnicity of Pediatric Residents and Fellows: 2007-2019

BACKGROUND AND OBJECTIVES

A diverse pediatric workforce reflecting the racial/ethnic representation of the US population is an important factor in eliminating health inequities. Studies reveal minimal improvements over time in the proportions of underrepresented in medicine (URiM) physicians; however, studies assessing trends in pediatric URiM trainee representation are limited. Our objective was to evaluate longitudinal trends in racial/ethnic representation among a cross-section of US pediatric trainees and to compare it to the US population.

METHODS

Repeated cross-sectional study of graduate medical education census data on self-reported race/ethnicity of pediatric residents and subspecialty fellows from 2007 to 2019. To evaluate trends in URiM proportions over time, the Cochran-Armitage test was performed. Data on self-reported race/ethnicity of trainees were compared with the general population data over time by using US Census Bureau data.

RESULTS

Trends in URiM proportions were unchanged in residents (16% in 2007 to 16.5% in 2019; P = .98) and, overall, decreased for fellows (14.2% in 2007 to 13.5% in 2019; P = .002). URiM fellow trends significantly decreased over time in neonatal-perinatal medicine (P < .001), infectious diseases (P < .001), and critical care (P = .006) but significantly increased in endocrinology (P = .002) and pulmonology (P = .009). Over time, the percentage of URiM pediatric trainee representation was considerably lower compared to the US population.

CONCLUSIONS

The continued underrepresentation of URiM pediatric trainees may perpetuate persistent health inequities for minority pediatric populations. There is a critical need to recruit and retain pediatric URiM residents and subspecialty fellows.

Extending "Beyond Diversity": Culturally Responsive Universal Design Principles for Medical Education

This commentary follows up on Maduakolam et al. (2020) "Beyond Diversity: Envisioning Inclusion in Medical Education Research and Practice," which introduced Culturally Responsive Universal Design for Learning (CRUDL) as an approach to accounting for learner diversity in educational theory development and curriculum design. We flesh out the principles of CRUDL, using publications in this issue of Teaching and Learning in Medicine as case examples for how the principles work in action. With this scholarly thought exercise, we seek to demonstrate the feasibility and promise of curriculum that is accountable to diverse learners and the impact of historical trauma. We also explore how research inclusive of diverse social identities could inform curriculum design by identifying how social identity, learning environment, educational activities, and learner engagement interact to produce diverse learning experiences and performance. Scholarly thought exercises such as this one may help bridge the gap between professed ideals and action with respect to inclusive medical education; CRUDL principles provide a helpful framework for planning and evaluating accountable curriculum design.

Full-Time Faculty in Clinical and Basic Science Departments by Sex and Underrepresented in Medicine Status: A 40-Year Review

PURPOSE

To assess the changing diversity of faculty in specific clinical and basic science departments, stratified by sex and underrepresented in medicine (URM) status, at all Liaison Committee on Medical Education (LCME)-accredited medical schools.

METHOD

In this retrospective, cross-sectional, observational study, the authors used data from the Association of American Medical Colleges Faculty Roster (data pulled in October 2019) to identify trends in clinical department faculty and in basic science department faculty by sex and URM status. They included full-time faculty at all LCME-accredited medical schools from 1979 to 2018. They compared the proportions of faculty across separate departments according to sex and URM status, and they used 2-independent-sample t test and simple linear regressions for statistical comparisons.

RESULTS

The number of full-time faculty increased from 49,909 in 1979 to 175,326 in 2018. The largest increase occurred in clinical departments, where the number of faculty increased from 38,726 to 155,677 (a fourfold increase). The number of faculty in basic science departments increased from 11,183 to 19,649 (a 1.8-fold increase). The proportions of faculty who were non-URM females (compared with non-URM males, URM females, and URM males) increased the most-from 14.4% (5,595 of 38,726) to 37.6% (58,478 of 155,677) for clinical departments, and from 14.9% (1,669 of 11,183) to 33.0% (6,485 of 19,649) for basic science departments. Growth was steady but slow among URM faculty, especially for Black males; the absolute number of male URM faculty remained low in both basic science and clinical departments. The proportions of females and URM faculty were highest in the departments of obstetrics and gynecology, pediatrics, and family medicine.

CONCLUSIONS

The substantial increase in faculty, especially in clinical departments, has led to greater diversity, but mostly among non-URM females. The rise of URM male and URM female faculty has been minimal.

Affirmative Action in Medical School: A Comparative Exploration

A significant body of evidence shows that law schools and many elite colleges use large admissions preferences based on race, and other evidence strongly suggests that large preferences can undermine student achievement in law school and undergraduate science majors, thus producing highly counterproductive effects. This article draws on available evidence to examine the use of racial preferences in medical school admissions, and finds strong reasons for concern about the effects and effectiveness of current affirmative action efforts. The author calls for better data and careful investigation of several identified patterns.