Remaining Steadfast During Times of Uncertainty—Recruiting a Diverse GME Physician Workforce to Achieve Health Equity

As leaders in graduate medical education (GME), we have a duty to the public to recruit and train a physician workforce equipped to improve the health of individual patients and populations. There are ample data to tell us that diverse workforces provide better care to patients.¹ This includes reducing health disparities among minoritized populations.^2,3 Physician-patient racial concordance has been demonstrated to reduce mortality for people as young as newborn infants.⁴ Additionally, we know that physicians who are trained in diverse teams, regardless of their own race and ethnicity, provide better care for people from historically minoritized communities when they enter clinical practice. There is recognition that culture, diversity, and inclusion are essential to the practice of high-quality clinical care in medicine. It has been well articulated in academic medicine literature that diversity in health care is a means to increase access to care for underserved populations, reduce health disparities, share a more inclusive biomedical research agenda, and enhance the cultural competence of clinicians.⁵ Finally, a truly just society demands that our medical community is welcoming and inclusive of physicians from all backgrounds. Therefore, aiming for a diverse GME learning community is an important goal for all of us in GME.

It is crucial for us to remain steadfast to this mission as we approach GME recruitment in a changed legal environment. The recent US Supreme Court decisions, Students for Fair Admissions Inc v Presidents and Fellows of Harvard College and Students for Fair Admissions Inc v University of North Carolina, may not initially impact GME, because residents and fellows are employees rather than students and are therefore covered under Title VII of the Civil Rights Act of 1964 rather than under Title VI.^6,7 However, these Supreme Court decisions will inevitability impact GME workforce diversity by narrowing the pipeline for medical students from underrepresented backgrounds. If one part of our physician pipeline is affected, we are all affected. Therefore, the recent Supreme Court decision threatens the progress that we have made thus far in improving the diversity of our health care workforce.

Several national organizations have commented on how this ruling will negatively affect the education of physicians.^8-10 Soon after the ruling, our own institution released a video confirming its commitment to diversity in our health professions workforce while noting it will abide by the Supreme Court ruling.¹¹ It was important to tell our community that our goals and mission are unchanged. As residents and clinical fellows are considered to be both employees and learners, the Accreditation Council for Graduate Medical Education has taken the view that this recent decision does not directly impact recruitment strategies. While there has not been a case directly challenging approaches to recruitment and selection in residency and fellowship, or other aspects of employment law, that does not mean that a case will not be brought in the future. We should therefore be mindful of these rulings as we approach interview season.

Some institutions, as part of the holistic review, already mask applicant race, ethnicity, and photograph during the initial screening process. It is likely that, under guidance from their legal teams, an increasing number of institutions will do so. However, unless we, as a GME community, identify alternative means to recruiting physicians from historically minoritized groups, we will not meet the needs of our patients and the communities we serve. One potential approach is to modify the Electronic Residency Application Service to include a question, much like the current common medical school application, about major challenges or obstacles an applicant has overcome in life including lived experiences related to family background, financial background, community setting, educational background, or other life experiences. Doing so may allow us to continue to meet our mission while remaining within the confines of the law.

Here we propose a mission-driven approach to recruitment, which emphasizes the essential commitment we have to improving the care of the US population—which means continuing to advocate for an approach to diversifying our physician workforce.

1. Consider messaging. Sponsoring institutions (SIs) and individual programs should consider their messaging to applicants. Review your website, any social media, and other recruitment documents. Think about your messaging within the interview process. Emphasizing a diverse health professions workforce committed to promoting health equity may be an important part of your mission, and if so, be sure your messaging shares that aspect.

2. Review your current diversity initiatives, such as visiting elective programs, including their advertisements and listed selection criteria. These initiatives should not impose requirements of race or ethnicity for participants. However, they may emphasize the importance of a diverse physician workforce and also include that participants should be committed to promoting health equity.

3. Ensure that you have a uniform recruitment approach within your SI. Designated institutional officials and their teams should ensure that sponsored programs are sharing a similar message regarding their approach to recruitment and selection.

4. Use a holistic approach for application review.¹² The Association of American Medical Colleges has resources available online to assist with this approach.¹³ We recommend using these tools as well as other changes to the application that could improve this process.

5. Remain committed to your ultimate mission and goals. Remember the need for a diverse workforce to provide optimal patient care and continue to recruit physicians (of any background) who are committed to advancing health equity.

Although we are focused on this year’s recruitment, we must also be mindful of what may occur in the future. Some in legal circles believe that challenges to affirmative action practices by employers will be next. This could more directly impact approaches to recruitment and interviewing of GME applicants, as well as GME faculty recruitment. For now, it is essential not to let fear and anxiety guide our actions. While the future may hold more legal questions, we must continue to be committed to our mission today and not have a possible future ruling affect our behavior now. We know from research that recruiting for a diverse workforce will provide better care for our patients, deliver benefits to individual clinicians, and improve the health care provided to the public.^14,15