Keeping Our Promise — Supporting Trainees from Groups That Are Underrepresented in Medicine

Now that the 2021 U.S. residency-program match is over, program directors are assessing the success of their diversity-recruitment efforts. In the wake of historic racial unrest and a subsequent recommitment to racial equity by academic medical centers, many program directors embraced holistic reviews of applicants, highlighting talents and skills (e.g., grit) that are frequently overlooked in standard review processes. Residency programs sought to broaden racial and ethnic representation by hosting diversity fairs, revising mission statements to promote inclusive learning environments, adding antiracism statements to their websites, and promoting community service on social media. We are proud that 11 of 22 program directors at our institution, the University of Chicago, opted not to use U.S. Medical Licensing Examination scores for interviewee selection or candidate ranking. In our internal medicine residency program, 84% of applicants belonging to groups that are underrepresented in medicine interviewed with at least one faculty member from an underrepresented group, and 11% interviewed with two such faculty members.

Some programs were richly rewarded for their efforts. Overall, one quarter of University of Chicago Medicine system trainees in the 2021–2022 intern cohort are members of underrepresented groups. Other academic institutions are celebrating recruiting their most diverse intern class to date. They have good reason to celebrate. The addition of a critical mass of minority interns will enhance the learning environment for existing minority trainees in ways that can support their well-being and performance, such as by reducing social isolation and stereotype threat (the fear of confirming stereotypes about one’s social group, which can undermine performance). Working alongside trainees who belong to underrepresented groups can benefit other trainees by reducing their implicit bias¹ and improving their skills in caring for diverse populations.² Minority trainees will ultimately enhance the lives of patients of color, for whom having race-concordant physicians has been associated with higher-quality relationships, communication, and health care delivery. An influx of minority trainees can signal a change in organizational priorities and lift the spirits of all employees, particularly employees of color, in a hospital system.

Of crucial importance is ensuring that institutions recruiting diverse intern cohorts are prepared to support new trainees on arrival and throughout residency. Recent data from the Accreditation Council for Graduate Medical Education reveal that Black, Asian, and Latinx trainees are dismissed from training programs at higher rates than White trainees, though the reasons for dismissal haven’t been studied. Dismissal causes substantial professional, emotional, and financial harm to minority trainees and negatively affects future patients who would have benefited from their care. Disproportionately high dismissal rates reflect the graduate medical education system’s failure to address the training needs of marginalized residents.

We believe that academic hospitals must make changes to help minority trainees thrive. Four key strategies would improve the organizational climate at various institutions and enhance trainees’ potential for success (see box).

Key Resources and Practices for Supporting Trainees from Groups That Are Underrepresented in Medicine.

Leadership and Infrastructure for Diversity, Equity, and Inclusion (DEI)

Skilled and well-resourced DEI officers

Officers that are appropriately titled, recognized as essential to strategic planning, and compensated

Diversity committee, with members (trainees and faculty) who are compensated for time and recruitment efforts

Affinity group support and resources

Accessible online list of faculty from underrepresented groups

Recruitment initiatives, such as outreach to societies with large numbers of members of underrepresented groups, with DEI officers included in interviews

Search committee practices to increase minority faculty, such as maintaining and reporting demographic metrics for applicants, interviewed applicants, and applicants offered positions

Review of promotion practices to increase success of minority faculty: Where are minority faculty facing obstacles? How much time are minority faculty spending at each level of promotion, as compared with other faculty? Are promotions committees diverse? Are promotions officers and committees required to be trained in bias reduction?

System-Level Changes Promoting Health Equity

Well-resourced community outreach and engagement efforts

Advocacy training for supporting individual patients and groups with chronic diseases and for promoting distributive justice

Well-resourced trainee clinics

Clinical performance metrics stratified by social risk factors

Quality improvement and health care delivery system redesign with an equity lens

Structural Competency and Advocacy Training

Lectures on the history of the Flexner Report, the American Medical Association’s discriminatory practices, scientific racism, and structural racism

Morning-report cases demonstrating the effects of bias, discrimination, inequitable practices (i.e., lack of lessons on dermatologic conditions on darker skin), and racialized medicine (e.g., pulmonary function tests and estimated glomerular filtration rate calculations)

Instruction in how structural violence against marginalized populations causes or exacerbates diseases such as diabetes, hypertension, chronic kidney disease, and HIV

Bias-Reporting Mechanisms

Reporting mechanisms for bias that are free from retribution, protect reporters, and are accountable for changes in the offender’s behavior

First, we believe that institutions should have well-structured diversity, equity, and inclusion (DEI) platforms. DEI officers must be trained in critical race theory, health disparities, and inclusive pedagogy and be able to offer programming on topics ranging from implicit bias to civil discourse. These officers should be people who identify as members of a marginalized group, so that they have shared, authentic lived experiences with discrimination and a personal drive to address these issues. DEI officers who are members of underrepresented groups can serve as role models and mentors. When it comes to conducting diversity training, a trainer’s personal experience with discrimination affects perceptions of their effectiveness.³

Every DEI officer could report and respond to a diversity committee that includes both trainees and faculty. Diversity committee members should be consulted on new clinical and educational endeavors, and institutions should compensate members for this additional work — for instance, by counting diversity-related work as part of their salaried responsibilities, providing them with administrative support, or offering additional training that enhances their career trajectories.

To ensure that equity is consistently considered in strategic planning and policy decisions, every major institutional leadership group could include a DEI officer. Every department, section, and residency program could have an identified officer.

Although DEI officers bring expertise and focus to equity efforts, true organizational change requires building a culture of equity throughout the institution, from senior leadership to frontline staff. Strong DEI infrastructure is only one part of the necessary commitment to equity at academic hospitals.

Institutions could also establish and support affinity groups — groups with shared race, culture, gender, sexual orientation, or other identities. Affinity groups foster personal relationships and build the social capital and sense of belonging that help trainees succeed. They also foster mentoring relationships, facilitate access to institutional resources, and buffer the harm associated with imposter syndrome, social isolation, and stereotype threat that may affect trainees.⁴ Separately, trainees from underrepresented groups should be able to interact with successful, well-resourced faculty from similar backgrounds. Trainees should have access to a database of such faculty.

Second, there is a need for system-level changes promoting health equity. Many trainees from underrepresented groups want to advocate for and serve underresourced communities. Doing so should not require extra effort. Hospitals should support community outreach, community service, and connections with community-based organizations for all trainees. Residents need training in supporting individual patients (e.g., making referrals and navigating insurance-related issues) and groups with chronic diseases (e.g., sickle cell disease) and in promoting distributive justice (e.g., in the area of vaccine distribution).

Institutions must also challenge ideologies that permit the rationalization of differential underresourced care. Our trainees frequently care for the sickest patients from the most underresourced communities, including racial and ethnic minority groups. Yet ambulatory resident clinics often don’t feature the level of team-based care that is available to faculty in the same practice. Trainees should have access to social workers, behavioral health workers, and patient navigators to help care for patients with complex medical and social needs. Without such resources, we risk creating biases about these patients and their ability to be healthy, and we signal that they are second-class citizens. Prioritizing health equity for marginalized patients sends a strong institutional message to trainees, especially minority trainees, that all lives are equally valued. Residency review committees could adopt policies emphasizing health equity. More broadly, academic hospitals could stratify care quality measures by patient race and ethnic group, perform continuous root-cause analyses of disparities in care and outcomes that engage affected patients and communities, and continuously redesign care systems to address drivers of these disparities.

Third, institutions could sponsor structural competency and advocacy training for staff, trainees, and teaching faculty. Structural competency training facilitates an understanding of social determinants of health, structural racism, and discrimination in the medical profession and can be informed by results of internal studies. Residents and faculty can review the legacy of the Flexner Report and the American Medical Association’s exclusionary practices, scientific racism, and the ways in which structural racism promotes health disparities. They can learn how structural violence against marginalized populations causes or exacerbates diseases such as diabetes, hypertension, chronic kidney disease, and HIV.⁵ Residents should undergo training in implicit bias, creating safe spaces, and allyship (bystander training).

Finally, institutions should have accountable systems for reporting bias. Residents and faculty could receive training on reporting episodes of discrimination and bias. Such episodes may negatively affect trainees by increasing their cognitive load, undermining their learning potential, reducing their career opportunities, or causing direct harm, and they can influence the care that trainees provide. Multiple mechanisms should protect identifying characteristics of reporters and prevent retribution. For example, all trainees should have easy access to an ombudsperson. Academic hospitals must be prepared to address reported incidents.

In recruiting diverse intern cohorts, residency programs have made an unspoken promise to provide a safe space for trainees to flourish. Breaking this promise will contribute to medicine’s damaging legacy of discrimination. Keeping this promise will begin healing a wound that must be closed in our generation — and could inspire the rest of the country to begin healing as well.