Addressing diversity in the physician workforce through social determinants of medical education

Abstract

Social determinants of medical education are the most impactful aspects of recruiting, retaining, and producing the next generation of a diverse physician workforce. We can use the same framework well known to describe social determinants of health to identify social determinants that impact medical education learners and their ability to enter the workforce and succeed to completion. Efforts aimed at recruitment and retention should not exist in isolation and must be matched with those that continuously assess and evaluate the learning environment. The development of a climate where all can bring their full selves to learn, study, work, and care for patients is critically important in the creation of a learning environment where every participant can grow and thrive. If we are to address the need to diversify the workforce, we must be intentional with strategic plans, which includes addressing the social determinants that are prohibitive for some of our learners.

Figure 1. Social Determinants of Medical Education

Physician shortages disproportionately impact medically underserved areas (MUAs) that inherently serve vulnerable patient populations who also suffer from socioeconomic instability, historical exclusion, and discrimination. In being the largest producers of the physician workforce, graduate medical education and its academic partners would benefit in strategically planning for how to build a diverse physician workforce and identifying how to address the physician shortage in MUAs. ¹

Social determinants of medical education (SDME) are the most impactful aspects of recruiting, retaining, and producing the next generation of a diverse physician workforce. ² While social determinants of health are conditions within the social, cultural, environmental, economical, and even historical background that impact a patient's health and health care, the same can be said about the conditions which affect the medical education learners. Muller et al. ³ discusses this new paradigm whereby medical educators, academic medical centers and their leaders need to consider the social determinants that their medical students and postgraduate trainees bring to their education and training. Even further, these considerations help identify the causes of the underlying disparities that exist in the recruitment and retention of a diverse workforce.

If we use the same five areas well known to describe social determinants of health, we can identify examples of social determinants which impact medical education learners ² : (1) access to and quality education—lack of access to STEM programs in K‐12, lack of medical school preparatory or pathway programs, and nonholistic reviews for acceptance into medical school and residency training; (2) social and community context—lack of mentorship, social isolation/exclusion due to macro‐ and microaggressions in the learning environment, and family‐ and community‐related responsibilities; (3) neighborhood and the built environment—rising rent cost leading to residence in unsafe housing conditions versus job/training availability; (4) access to and quality health care—stigmatization of mental health disorders and lack of access to mental health services; and (5) economic stability—student loan indebtedness.

All of these SDME are exacerbated by the political and economic landscape of the country, thereby allowing the pandemic and its myriad of related consequences to create even more disparate conditions. To address these inequities and lack of diversity in the physician workforce, we must place greater emphasis on those determinants that our learners, if they are even able to overcome the barriers, carry with them into the learning environment.

Structural competency is “the ability of physicians (faculty and trainees) to discern how ‘downstream’ issues such as symptoms, attitudes, and diseases are influenced by ‘upstream’ social determinants of health (such as health care and food delivery systems, zoning laws, urban and rural infrastructures, and medicalization).” ⁴ In applying this to SDME, medical education leaders need to recognize the structural competency of their institutions, such that they identify “upstream” issues that cause potential “downstream” impact on academic and clinical performance of their learners. We, as institutions, need to understand, research, and develop the solutions for these issues to recruit, retain, and allow the next generation of a diverse physician workforce to flourish and thrive.

This process does not happen without deliberate effort and intentionality. In fact, the same intentionality that led to effective programs that have created the inequities described must be utilized to overcome the systemic and structural barriers that have allowed them to persist for decades. Engagement of both senior leadership and program directors in active processes have proven successful at multiple organizations and across multiple specialties. ⁵ , ⁶ , ⁷ These goals must be specific and supported by targeted interventions and progress against goals should be reported and reviewed at the highest levels of the organization in the same manner and with the same attention as operational and financial metrics. Program‐level as well as systemwide reports, which compare local data to national benchmarks, can facilitate effective tracking, stimulate engagement, and introduce transparency (see Table 1).

TABLE 1.

Examples of intentional recruitment and retention programs.

	Description	SDME
Recruitment
Pathway programs for URiM students	Summer programs to introduce college students to medicine while also providing them academic support, including MCAT preparation. Successful completion of the programs leads to admittance to medical school. Shadowing, clinical, and research exposure during high school and college. Stipend for summer programs.	Access to quality education Mentorship/sponsorship Economic stability
Graduation medical education and faculty affairs collaboration	Longitudinal programming to build community and support a sense of belonging. Addressing culture and climate to support trainees and junior faculty in the pursuit of an academic career. Sharing best practices across institutions.	Access to quality education Mentorship/sponsorship Community and cultural context
Subsidized electives for medical students to participate in “away electives”	Stipend for students to complete visiting elective rotation. Facilitate social connections between visiting students and current residents. Collaboration in recruitment across training programs at a sponsoring institution. Mentorship of rotating students.	Economic stability Access to quality education Mentorship Community and cultural context
Retention
Facilitate the creation and maintenance of a diverse and inclusive learning environment	Bystander training. Creation, development, and dissemination of a common language and a “culture code” that describes how members of the community interact with and treat each other.	Community and cultural context
Mentorship programs	Pairing interns with more senior residents as part of a community cohort. Resident and faculty panels and conversations where members of the URiM community can share experiences in a safe environment.	Mentorship/sponsorship Community and cultural context
Building community connections	Resident‐led initiatives in community engagement, social justice, health equity research, recruitment of diverse workforce, and mentorship for URiM trainees and faculty. Create community for URiM trainees and faculty.	Mentorship Community and cultural context
Growth and vitality
Vitality and professional fulfillment data	Annual surveys to assess the learning environment as well as the vitality and professional fulfillment of all staff. Understanding that experiences of occupational well‐being differ based on people's personal identities including race and gender. A health equity approach prioritizes solutions that address inequities and disparities in drivers of vitality.	Community and cultural context Access to mental and physical health services

Abbreviations: SDME, social determinant of medical education; URiM, underrepresented in medicine.

Efforts aimed at recruitment and retention should not exist in isolation and must be matched with those that continuously assess and evaluate the learning environment. The development of a climate where all can bring their full selves to learn, study, work, and care for patients is critically important in the creation of a learning environment where every participant can grow and thrive. Understanding that the needs of individuals may vary given the inequities and SDME that have influenced their pathway to residency, organizations must strive to offer the community, support, mentorship, and sponsorship to allow all to achieve their potential. The implementation of initiatives and processes, which address micro‐ and macro‐aggressions, and also provide frameworks that facilitate and encourage bystanders to speak out, also contribute to an environment that is more welcoming and inclusive.

As we all look toward creating more diverse and inclusive work environments, it is important as the leaders of graduate medical education at both the system and the program levels to align in our efforts to address the SDME that our learners carry with them into their work and educational environment. We must be intentional about developing strategies that do more than touch the surface of longstanding racism and inequities within our society and medicine.

CONFLICT OF INTEREST STATEMENT

The authors do not have any disclosures to report.

Smith TY, Landry A, Schneider JI. Addressing diversity in the physician workforce through social determinants of medical education. AEM Educ Train. 2023;7(Suppl. 1):S88–S90. doi: 10.1002/aet2.10874