Abstract
This survey study evaluates the perceived barriers of minority medical students pursuing a career in dermatology.
As the US population becomes increasingly diverse, the specialty of dermatology has not followed this trend; it is the least diverse medical field, after orthopedics.1 Although African Americans and Hispanics compose 12.8% and 16.3% of the American population, respectively, each group represents less than 5% of dermatologists (https://www.census.gov/prod/cen2010/cph-1-1.pdf).2 The representation of minorities improves patient care because race-concordant visits are associated with longer visits and greater patient satisfaction.3,4 Recently, several calls to action have endorsed evidence-based research to understand barriers to minority students pursuing dermatology.1,5,6
Methods
All research activities for this study were deemed exempt from ethical review by the institutional review board of Albert Einstein College of Medicine (IRB 2017-8705); nonetheless, all survey respondents provided written informed consent before completing the survey. A survey was conducted between January and April 2018 to investigate the lack of diversity and barriers to applying for a dermatology residency. The survey was electronically sent to 35 medical schools. Demographic information was collected, and participants were asked to rate survey items on a Likert scale (1, not important to 5, very important). Minorities were defined as nonwhite persons, and lower-income students were defined as those with annual household incomes below $40 000. Analysis was performed with SPSS Version 24.0 (IBM Corp).
Results
The survey was completed by respondents from 28 of 35 medical schools (school response rate, 80%). It was accessed by 242 medical students and completed by 155 of them (student response rate, 64%). Demographic characteristics are detailed in Table 1. Of the participants 43.2% (n = 67) expressed an interest in applying for a dermatology residency. Overall, participants cited the following factors as the most important (mean [SD] Likert score) to applying for a dermatology residency: US Medical Licensing Examination Step 1, 4.91 (0.35); clinical grades, 4.70 (0.59); and risk of not matching, 4.53 (0.76) (Table 2).
Table 1. Survey Participant Demographic Information.
| Characteristic | Students, No. (%) |
|---|---|
| Medical school geographic regions | |
| Northeast | 86 (55.5) |
| Midwest | 46 (29.7) |
| South | 5 (3.2) |
| West | 1 (0.6) |
| Puerto Rico | 1 (0.6) |
| Foreign | 14 (9.0) |
| Expected graduation year | |
| 2018 | 47 (30.3) |
| 2019 | 25 (16.1) |
| 2020 | 37 (23.9) |
| 2021 | 38 (24.5) |
| 2022 | 2 (1.3) |
| Physician in family? | |
| Yes | 99 (63.9) |
| No | 56 (36.1) |
| Prior dermatology experience | |
| Yes | 43 (27.7) |
| No | 112 (72.3) |
| First language | |
| English | 123 (79.4) |
| All others | 32 (20.6) |
| Race | |
| African American | 24 (15.5) |
| White | 65 (41.9) |
| Asian | 42 (27.1) |
| Middle Eastern and/or North African | 11 (7.1) |
| Multiple races | 6 (3.9) |
| Other | 6 (3.9) |
| Ethnicity | |
| Hispanic/Spanish/Latino | 14 (9.0) |
| Non-Hispanic/Spanish/Latin | 139 (89.7) |
| Country of birth | |
| Other | 45 (29.0) |
| United States | 110 (71.0) |
| LGBTQIA | |
| Yes | 17 (11.0) |
| No | 137 (88.4) |
| Average household income growing up, $ | |
| >100 000 | 71 (45.8) |
| 80 000-100 000 | 23 (14.8) |
| 60 000-80 000 | 17 (11.0) |
| 40 000-60 000 | 15 (9.7) |
| 20 000-40 000 | 17 (11.0) |
| <20 000 | 9 (5.8) |
Abbreviation: LGBTQIA, lesbian, gay, bisexual, transgender, queer, intersex, and asexual.
Table 2. Survey Results by Race, Ethnicity, and Household Income Using a Likert Scalea.
| Characteristic | Likert Value, Mean (SD) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Preclinical Grades | Clinical Grades | Honors/Awards/Distinctions | USMLE Step 1 | USMLE Step 2 | Lack of Evident Diversity | Ability to Gain LOR/Networking | Poor Accessibility to Mentors | Burden of Research Year | Socioeconomic Barriers | Risk of Not Matching | Perceived Exclusivity of the Field | Negative Perceptions of Minority Students by Residency Programs | |
| Race | |||||||||||||
| African American | 3.46 (1.47) | 4.71 (0.62) | 4.38 (0.88) | 4.83 (0.57) | 4.00 (0.93) | 4.13 (1.15) | 4.46 (0.78) | 4.63 (0.71) | 4.54 (0.88) | 4.25 (1.03) | 4.71 (0.62) | 4.54 (0.72) | 3.96 (1.16) |
| White | 3.28 (1.59) | 4.78 (0.48) | 4.55 (0.81) | 4.95 (0.21) | 3.91 (1.07) | 3.25 (1.36) | 4.35 (0.86) | 4.03 (1.03) | 4.17 (1.00) | 3.55 (1.37) | 4.32 (0.94) | 3.98 (1.17) | 2.46 (1.40) |
| Asian | 3.12 (1.58) | 4.71 (0.64) | 4.21 (1.09) | 4.88 (0.40) | 4.33 (1.00) | 3.60 (1.25) | 4.50 (0.83) | 4.14 (0.98) | 4.27 (0.98) | 4.24 (1.02) | 4.66 (0.58) | 4.17 (0.97) | 3.20 (1.35) |
| MENA | 3.09 (1.64) | 4.82 (0.41) | 4.73 (0.47) | 4.91 (0.30) | 4.18 (0.60) | 3.64 (1.29) | 4.64 (0.51) | 4.55 (0.93) | 4.64 (0.51) | 4.36 (0.81) | 4.73 (0.47) | 4.36 (0.81) | 3.27 (1.49) |
| Multiple races | 3.17 (1.47) | 4.17 (0.75) | 4.33 (0.52) | 5.00 (0.00) | 4.33 (1.03) | 3.67 (0.52) | 4.17 (0.75) | 4.17 (0.75) | 4.33 (0.52) | 4.00 (0.63) | 4.67 (0.52) | 4.33 (0.52) | 3.00 (0.89) |
| Other | 3.50 (1.05) | 4.00 (0.63) | 4.17 (0.88) | 4.83 (0.41) | 4.33 (0.52) | 4.33 (0.82) | 4.00 (0.89) | 4.67 (0.52) | 4.17 (1.33) | 4.50 (0.84) | 4.67 (0.52) | 4.83 (0.41) | 4.17 (1.17) |
| P valueb | .96 | .01c | .34 | .68 | .34 | .05 | .58 | .08 | .51 | .02c | .13 | .13 | <.001c |
| Ethnicity | |||||||||||||
| Hispanic/Spanish/Latino | 3.29 (1.49) | 4.36 (0.75) | 4.50 (0.65) | 4.93 (0.27) | 4.43 (0.51) | 4.50 (0.65) | 4.29 (0.83) | 4.79 (0.43) | 4.54 (0.66) | 4.15 (1.14) | 4.69 (0.48) | 4.62 (0.51) | 4.00 (1.08) |
| Non-Hispanic/Spanish/Latino | 3.22 (1.55) | 4.73 (0.56) | 4.40 (0.91) | 4.91 (0.36) | 4.04 (1.02) | 3.47 (1.29) | 4.42 (0.81) | 4.16 (0.98) | 4.27 (0.96) | 3.92 (1.22) | 4.51 (0.78) | 4.17 (1.03) | 2.96 (1.44) |
| P valueb | .87 | .09 | .70 | .82 | .17 | <.001c | .56 | <.001c | .33 | .51 | .41 | .13 | .005c |
| Household income, $ | |||||||||||||
| >100 000 | 3.13 (1.61) | 4.72 (0.54) | 4.55 (0.77) | 4.92 (0.33) | 3.86 (1.13) | 3.13 (1.38) | 4.21 (0.86) | 3.96 (1.05) | 4.18 (1.00) | 3.59 (1.29) | 4.38 (0.83) | 4.10 (1.07) | 2.56 (1.36) |
| 80 000-100 000 | 3.00 (1.51) | 4.70 (0.64) | 4.09 (1.08) | 4.96 (0.21) | 4.35 (0.83) | 3.61 (1.08) | 4.57 (0.79) | 4.26 (0.92) | 4.17 (0.94) | 3.65 (1.40) | 4.30 (0.97) | 4.00 (1.28) | 3.30 (1.26) |
| 60 000-80 000 | 3.18 (1.51) | 4.59 (0.62) | 4.47 (0.94) | 4.71 (0.69) | 4.12 (0.78) | 3.71 (1.11) | 4.59 (0.80) | 4.41 (0.71) | 4.35 (1.06) | 4.35 (0.79) | 4.88 (0.33) | 4.18 (0.81) | 3.06 (1.35) |
| 40 000-60 000 | 3.33 (1.50) | 4.73 (0.46) | 4.20 (1.15) | 5.00 (0.00) | 4.20 (0.68) | 4.00 (1.13) | 4.33 (0.82) | 4.07 (1.03) | 4.13 (0.99) | 4.33 (0.90) | 4.67 (0.49) | 4.33 (0.72) | 3.27 (1.53) |
| 20 000-40 000 | 3.71 (1.49) | 4.71 (0.59) | 4.47 (0.94) | 4.94 (0.24) | 4.29 (0.69) | 4.41 (0.87) | 4.59 (0.71) | 4.71 (0.59) | 4.69 (0.60) | 4.56 (0.73) | 4.75 (0.58) | 4.50 (0.82) | 4.19 (1.17) |
| <20 000 | 3.33 (1.41) | 4.67 (1.00) | 4.33 (1.00) | 4.89 (0.33) | 4.78 (0.44) | 4.22 (0.97) | 4.78 (0.44) | 4.89 (0.33) | 4.89 (0.33) | 4.78 (0.44) | 4.89 (0.33) | 4.67 (0.50) | 3.67 (1.41) |
| P valueb | .77 | .98 | .32 | .20 | .40c | .004c | .12 | .01c | .15 | .004c | .03c | .38 | <.001c |
| Total Likert value, mean (SD) | 3.24 (1.54) | 4.70 (0.59) | 4.42 (0.88) | 4.91 (0.35) | 4.09 (0.99) | 3.56 (1.28) | 4.41 (0.81) | 4.22 (0.96) | 4.29 (0.95) | 3.95 (1.20) | 4.53 (0.76) | 4.19 (1.00) | 3.04 (1.43) |
Abbreviations: LOR, letter of recommendation; MENA, Middle Eastern and/or North African; USMLE, US Medical Licensing Examination.
Likert scale (1 = not important, 2 = slightly important, 3 = important, 4 = fairly important, 5 = very important).
By analysis of variance (ANOVA) or 2-sided t test.
P value significant after Benjamini-Hochberg adjustment for multiple comparison with FDR (false discovery rate) = 0.10.
Students with lower incomes and ethnic minorities cited the lack of diversity in dermatology as a significant factor; the highest scores were among Hispanic/Spanish/Latino students (4.50 [0.65]) and those with household incomes between $20 000 and $40 000 (4.41 [0.87]) (Table 2). Students reported negative perceptions of minority students by residency programs, such as expecting lower performance, to be important; the highest scores were among those identifying as “other” race (4.17 [1.17]), African Americans (3.96 [1.16]), Hispanic/Spanish/Latinos (4.00 [1.08]), and those with household incomes between $20 000 and $40 0000 (4.19 [1.17]). Racial minorities and low-income students were more likely to cite socioeconomic barriers, such as lack of loan forgiveness. The highest values were reported by those identifying as other races (4.50 [0.84]) and those with household incomes less than $20 000 (4.78 [0.44]). Hispanic/Spanish/Latino students (4.79 [0.43]) and those with household incomes less than $20 000 (4.89 [0.33]) reported the highest scores for poor accessibility to mentors, especially with which students can identify.
Study limitations included calculating accurate response rates (medical student respondents/number of medical students who received survey); participants may not represent all US medical students; and not all minority groups are underrepresented in medicine. Asians were included as minorities because 50.0% of respondents were born outside of the United States (n = 21), and 37.5% (n = 15) had a first language other than English. These participants are likely to have an “additional distance traveled,” a higher likelihood of addressing health care disparities, and may demonstrate “grit” compared with their peers.6 Study strengths include a diverse cohort representing many medical schools.
Discussion
Overall, participants cited US Medical Licensing Examination Step 1, clinical grades, and the risk of not matching as the most important barriers to applying for a dermatology residency. However, minority students reported the lack of diversity, perceived negative perceptions of minority students by residencies, socioeconomic factors, and lack of mentors as major barriers. The perceived barriers differ by the racial, ethnic, and socioeconomic backgrounds of students and highlight the need to actively recruit and mentor students of all backgrounds. Furthermore, efforts should be made to increase minority students’ exposure to dermatology by incorporating it into the curriculum, providing research opportunities, and reducing the cost of “visiting electives” by providing stipends.
References
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