SELF-EFFICACY TOWARD A HEALTHCARE CAREER AMONG MINORITY HIGH SCHOOL STUDENTS IN A SURGICAL PIPELINE PROGRAM: A MIXED METHODS STUDY

Abstract

Objective

While many barriers to healthcare careers exist for URM students, a strong sense of self-efficacy may help mitigate these obstacles. This study explores how URM high school students describe their academic challenges and to compare their descriptions across self-efficacy scores.

Design

We conducted a convergent mixed methods study of URM high school students. Students completed a validated self-efficacy questionnaire and participated in semi-structured focus group interviews to discuss their approach to academic challenges, goal setting, and achievement. The primary outcome was academic, social, and emotional self-efficacy, measured using the Self-Efficacy Questionnaire for Children. We separated participants into high and low self-efficacy groups based on scores in each domain. Using thematic analysis, we identified and compared common themes associated with academic challenges and goal setting.

Setting

Surgical exposure pipeline program sponsored by Stanford University Department of Surgery

Participants

Low-income, high academic achieving URM high school students interested in science technology engineering and mathematics and/or healthcare careers.

Results

Thirty-one high school students completed the focus groups and self-efficacy questionnaire. Most students scored in the high self-efficacy group for at least one domain: 65% for academic self-efficacy, 56% for social self-efficacy, and 19% for emotional self-efficacy. Four emergent themes highlighted participants’ perspectives toward educational success: fulfillment in academic challenges, focus on future goals, failing forward, and asking for help. Compared to students with low self-efficacy scores, students in the high-scoring self-efficacy groups more often discussed strategies and concrete behaviors such as the importance of seeking support from teachers and peers and learning from failure.

Conclusions

Students in high self-efficacy groups were more comfortable utilizing approaches that helped them succeed academically. Additional efforts are needed to bolster student self-efficacy, particularly in students from URM backgrounds, to increase diversity in medical schools.

Introduction

While 13.4% of people living in the United States identify as Black or African American¹, only 7% of U.S. Medical School matriculants are Black.² To address this pervasive problem, institutions and medical school accrediting bodies implemented new diversity accreditation standards in 2009. Over the past decade, however, applications from Black women to US medical schools instead have decreased and the rate of matriculation among Black, Hispanic, and American Indian or Alaska Native students has not changed significantly.³

Why aren’t more underrepresented minority (URM) students matriculating into US medical schools? Embarking on a career in medicine requires years of planning, delayed gratification, and the ability to envision success. In a study of Black high school juniors, students reported several factors that dissuaded them from pursuing healthcare careers including financial challenges, negative normative cultural values and traditions, perceptions of physicians, and perceived racism in the medical field and healthcare institutions.⁴ A strong sense of self-efficacy, or confidence in the ability to succeed or achieve a goal, is an integral part of becoming a healthcare professional; conversely, poor self-efficacy with regard to education and career goals may contribute to the perceived barriers to pursuing a career in medicine.^5,6 Furthermore, minority high school freshman who report a greater sense of belonging also report stronger intentions to persist at the beginning of the academic school year.⁷

Given the importance of self-efficacy and sense of belonging or identity for URM students’ academic success, development of these attributes is an area of keen interest among diversity pipeline programs.⁸ The primary aim of the current study was to compare how URM high school students currently enrolled in a STEM/healthcare pipeline program perceive their own academic challenges across domains of self-efficacy.

Methods

We conducted a convergent mixed methods study of URM high school students in a science, technology, engineering and mathematics (STEM) enhancement summer program to measure self-efficacy and to compare perspectives on academic achievement across high and low scoring groups. We partnered with Summer Math and Science Honors (SMASH) Academy⁹ a tuition-free three-year pipeline program, to create a medical module, SMASH-Med.^10,11 The SMASH-Med curriculum exposes URM Bay Area students to healthcare careers, especially those related to surgery, through interactive discussions with medical students, house officers, faculty, and advanced practice providers and a series of five hands-on workshops. Activities included laparoscopic and robotic simulation, cadaver labs, physical exam workshops, splinting, ultrasound, and suture labs, as well as an interactive panel session. Ninety-five students participated in the program in 2019.

We conducted focus groups among those who had attended at least one healthcare workshop. We used a criterion-based purposive sampling strategy while aiming for maximum representation. An open invitation to participate in focus groups was offered to all ninety-five students during a group meeting. Students who had an interest in healthcare careers were encouraged to attend, although students were not excluded by lack of healthcare career interest. Focus group questions were derived from literature review regarding self-efficacy and motivation theory and were designed to elicit perspectives on achieving goals, overcoming challenges and resilience, setting future goals, and interest in a healthcare career.¹² Focus group moderators, S.S.B. and K.L.Y., had postgraduate degrees and formal training in focus group moderation. Each session was audio-recorded and transcribed verbatim by a professional transcription service. Immediately after the focus group ended, respondents were asked to complete the Self-Efficacy Questionnaire for Children (SEQ-C), a 24-point questionnaire validated among middle and high school students (n=330) in southeastern United States with internal consistency estimates between 0.82 to 0.86.^13,14 Respondents were asked to answer the questions on a Likert-type scale with response options ranging from 1= “not very well” to 5= “very well”. This study was approved by the Stanford University Institutional Review Board.

Qualitative Data Analysis

Transcripts were checked for quality and speakers were deidentified. Codes were developed inductively by detailed review and organized using Dedoose, a web-based management software.¹⁵ After codes were discussed and agreed upon by coders, deductive codes related to self-efficacy were applied. The final codebook was re-applied to all transcripts with 100% agreement by coders. We analyzed coded transcripts using thematic analysis. The final codebook reached 100% interrater agreement amongst two coders.¹⁶ Two study team members (A.M.M. and K.L.Y.) reviewed all excerpts from the “self-efficacy” category of codes to conduct thematic analysis. Emergent themes were validated through triangulation and a systematic search for disconfirming evidence by the two team members.

Quantitative Data Analysis

SEQ-C survey questions are divided into three self-efficacy domains: academic, social, and emotional. Academic self-efficacy was defined as an individual’s belief that they can successfully perform academic tasks at specific levels.¹⁷ Social self-efficacy was defined as an individual’s confidence in his/her ability to engage in the social interactional task necessary to initiate and maintain interpersonal relationships.¹⁸ Emotional self-efficacy was defined as an individual’s convictions in one’s emotional functioning capabilities.¹⁹ For each of the survey domains, we assigned students who averaged three or less on a five-point Likert scale to the “low” self-efficacy group and those who averaged four or greater to the “high” self-efficacy group, consistent with previously published work.²⁰

We integrated qualitative and quantitative data through a joint display²¹ by comparing themes that emerged from focus group responses across high and low self-efficacy survey scores. By design, quantitative self-efficacy scores were not known at the time of thematic analysis.

Results

Thirty-one URM high school students completed the survey and participated in six focus groups (n=4–6 students each; Table 1). The majority of students (54.8%) were in their first year of the SMASH-Med program and 22 (71%) were female. Eight (25.8%) self-identified as African American/Black, 16 (51.6%) were Latinx, two (6.5%) were as Southeast Asian, and five (16.1%) were “Mixed race/Multiracial.” None self-identified as White (non-Latinx). The vast majority of respondents qualified for free or reduced-price lunch (77.4%) and 24 identified as first-generation Americans (77.4%).

Table 1.

Participant demographic characteristics

	First Year	Second Year	Total
Total	17 (54.8)	14 (45.2)	31 (100)
Sex, n (%)
Male	4 (12.9)	5 (16.1)	9 (29.0)
Female	13 (41.9)	9 (29.0)	22 (71.0)
Ethnicity, n (%)
African American	4 (12.9)	4 (12.9)	8 (25.8)
Latinx	9 (29)	7 (22.6)	16 (51.6)
Southeast Asian	2 (6.5)	-	2 (6.5)
Mixed race	3 (9.7)	2 (6.5)	5 (16.1)
Free or reduced-priced lunch, n (%)
Yes	13 (41.9)	11 (35.5)	24 (77.4)
No	4 (12.9)	3 (9.7)	7 (22.6)
First Generation, n (%)
Yes	14 (45.2)	10 (32.3)	24 (77.4)
No	3 (9.7)	4 (12.9)	7 (22.6)

In the SEQ-C surveys, most students placed in the high academic self-efficacy group (64.5%). A slight majority (54.8%) of students were in the high social self-efficacy group. The vast majority (80.6%) of students placed in the low in emotional self-efficacy domain.

Theme 1. Finding Fulfillment in Academic Challenges

Several participants commented on how they thrive and feel fulfilled in the face of academic challenges. Some noted they valued the pipeline program because it challenged them academically, compared to their school-based coursework, which they found under-stimulating:

… SMASH has helped me e-every time I’m here, I feel like I’m getting challenged. I’m really happy. Like, it actually makes me think. I’m not finishing [ the work] in five minutes. I’m finishing in an hour. But I feel more accomplished in the end. (A3F1)

A few participants noted the lack of diversity in academia and the physician workforce. While some expressed discouragement about anticipated challenges as URM students, others expressed a sense of pride as URM students in academia:

You don’t see a lot of people of color in med school. Being also a female in med school, it’s going to be hard. So, there’s a balance between academics, but there’s also a balance socially that you have to take… I feel like a big part of the social problems is just knowing that you made it into med school, and that your hard work and your dedication is paying off, and that you just have to keep pushing yourself through those obstacles. (F1F2)

Theme 2. Focus on Future Goals

Students noted the concrete steps necessary to achieve their proximal and future dreams, aspirations, and ambitions. One student reported skipping lunch with his friends to have an extra study hall with his math teacher. Upon further discussion, he revealed that his goal was to have a 4.0 grade point average (GPA) for his college applications. Many respondents similarly shared their willingness to sacrifice social activities to focus on their academic performance, with the primary goal of a strong GPA for college applications. Another student expressed the importance of taking advantage of programs such as SMASH-Med since it has been the only resource available to her to receive guidance on her journey to becoming a physician.

I think a really big challenge in general, I think it’s just a lack of exposure to…certain things, certain criteria. Sometimes, I know I don’t know all of the requirements to get into a medical school… I’ll understand what I can do when I’m there, but I won’t understand how to get there, and I think that’s something that’s challenging in itself… which is why I’m thankful for programs like this… ‘cause I can talk to people like you guys, who take your time out of your day, and you guys can then talk to us about the path we can take to medicine. (F2F2)

Theme 3. Failing forward

Although respondents mentioned feeling discouraged by academic failures, they focused on strategies for using their experiences with failure. Multiple respondents in different focus groups used the phrase “failing forward,” indicating widespread use of this phrase among participants outside of focus groups. Some noted that they learned more from failures than successes. All who commented on failure highlighted the importance self-growth that came with addressing obstacles, “I say that at every obstacle, I take something from it… They have a saying at SMASH..., ‘Failure is encouraged’ or ‘fail forward’ because every time you fail, you’re gonna learn something from it.” (A3F1). Several students described a complex self-management strategy of acknowledging the transience of negative emotions linked to failure and noting the value of learning from the mistakes, followed by compartmentalizing to continue working toward goals.

Theme 4. Asking for help

The topic of asking for help was discussed among multiple groups. Some noted that asking for help could seem daunting for fear of being perceived as incompetent. Others noted, however, that asking for help resulted in aid not only for themselves but also classmates who may have been struggling. One student shared an experience of being the only non-Mandarin speaking student in her high school Mandarin class. She noted initially feeling embarrassed to admit to her teacher that she did not understand the lectures. Rather than dropping the class, she mustered the courage to ask for help and initiate a relationship with her teacher remained strong long after the class ended. Many students commented on the academic value of developing relationships with teachers:

I’m scared to speak up, but… if I don’t say anything, I’m just gonna be stuck there, and I’m not gonna grow… I’m gonna have a closed mindset and I really want that open mindset. So, I just ask the questions, even if it means I’m gonna get judged for it, at least it’s gonna make sense in my head. (F1F2)

Students discussed seeking help from multiple sources. While frustration regarding poor formal academic instruction and high teacher turnover was expressed by multiple respondents, students discussed using Khan Academy²² and other online resources to supplement their classroom instruction.

Comparison of thematic findings across high and low self-efficacy groups

Upon integrating qualitative and quantitative findings, several overarching connections between themes emerged.

Academic self-efficacy.

Students in the low academic self-efficacy group described fear of intimidation or judgment when asking for help. Some also discussed overcoming the fear of asking for help by holding themselves personally accountable for their education. In contrast, students in the high self-efficacy group described an expanded set of resources for academic help including peers, individual help from teacher, and teaching assistants (Table 2). They spoke at length about sacrificing social time to get help with schoolwork and discussed the self-limiting effect of not asking for help. While both groups discussed learning from mistakes, students in the low academic self-efficacy group expressed vague attitudinal responses, while students in the high academic self-efficacy group provided concrete examples of how they learned from prior mistakes, sought resources, and changed behaviors.

Table 2.

Academic Self-Efficacy Joint Display with Qualitative and Quantitative Results

Qualitative Themes	Lowa Academic Self-Efficacy n=11 (35.5%)	Highb Academic Self-Efficacy n=20 (64.5%)
Fulfillment in academic challenges	“I decided to drown myself in honors and AP classes because my freshman year, I had a 4.0… The classes I took… were really easy, so I thought, ‘Let me challenge myself a little bit more, and let me sign up for honors and accelerated AP.’” (F1F2)	“You’re writing an essay or you’re doing homework or whatever. It’s so hard and it’s like, ugh, I hate it. But then, at the end of the day… when you’re writing something and then you turn it in that moment when you turn it in - oh my God - it feels so good ’cause you’re done. It’s like all that hard work, it’s over.” (D5F1)
Focus on future goals	“I’m not alone, and that whatever obstacles I may face, there’s always gotta be some type of solution to it. And to not let that scare me and to have that mindset of, you know, med school is something that I want. It’s something that is achievable. It’s not impossible to achieve. And I just have to keep working hard and have to keep pushing myself, because I know in that-- like, in the long run or in the end, uh, it’s gonna be worth it.” (F1F2)	“ I would definitely say my personal fulfillment would be number one because at the end of the day, how I feel about myself is what matters the most… I just thought, like, if I give up on this, there’s so many other things, also in college and just in life itself that you’re just like, ‘Oh, will I give up on that? I could give up on this too.’ So, the fact that I was able to push through this, it’s like I can push through anything.” (E1F2)
Fail forward	“I’d just say it’s okay to fail. You can learn from your mistakes and I definitely made a big bunch of mistakes. But, thankfully, I’ve learned from them.” (A6F1)	“We had a math test.. I probably hadn’t studied as much as I should have… And when I got it back, it said C… I was freaking out… I was, like, going over my test and I realized all the mistakes I had made… If I just slowed down and checked over that, I would have gotten that problem right, which probably could have resulted in the rest of the problems on the test being right. So, from there on, I always reread over my test when I’m done and double check it multiple times as I go.” (B5F1)
Asking for help	“I’m scared to ask questions, because I feel like then teachers think I’m either dumb, or they just don’t want to… waste their time on me.” (F1F2)	“I just wanna, like, make sure to, like, better myself…asking for help is just extremely beneficial because the teacher isn’t the one that’s gonna be hurting. It’s gonna be you.” (B1M2)

^a<4 on a five-point Likert scale

^b≥4 on a five-point Likert scale

While discussing coping mechanisms in the setting of academic self-efficacy, students in both groups stressed the importance of self-soothing; however, students in the high academic self-efficacy group also noted the benefit in surrounding themselves with a community of “like-minded” individuals and the awareness that emotions are transient. Students in the high academic self-efficacy group often provided clear examples about how they have learned from academic failures.

Social self-efficacy.

Students from both low and high social self-efficacy groups discussed using social self-efficacy to support their academic goals (Table 3). Students in the low social self-efficacy group discussed the sequela of social hardship on their academic performance. As one participant noted, “My transition just out of middle school was really hard. I struggled socially more than I did academically. But then [by] socially, like not succeeding, I, like, academically started to fall.” (F2F2). Students in the high social self-efficacy group noted the occasional necessity of changing their social situation to improve their academic performance.

Table 3.

Social Self-Efficacy Joint Display

Qualitative Themes	Quantitative Survey Results
	Lowa Social Self-Efficacy n=14 (45.2%)	Highb Social Self-Efficacy n=17 (54.8%)
Fulfillment in academic challenges	“I guess what, motivates me towards health care is the… long journey because I know that getting into healthcare here in the United States is… really, really hard. And being an undocumented student and seeing other undocumented students, makes me… I wanna show them that… you can get there.” (A2M2)	“I really liked to do better than others. Like, me and my friends are all in the higher classes. Whenever one person gets one grade on a test, we try to one-up each other. It’s almost like friendly competition that keeps me motivated to do well.” (B5F1)
Focus on future goals	“My transition just out of middle school was really hard. I struggled socially more than I did academically. But then [by] socially, like not succeeding, I, like, academically started to fall.” (F2F2)	“Find balance between academics and personal time... too much [academic] involvement you won’t be able to just socialize, have fun... If you have too much fun, your grades are gonna drop. So, I feel like just finding, like, the right balance and maintaining that throughout your years of education, stuff like that is very useful.” (B6F1)
Fail forward	“I think something I take away is we all go through hard things and have similar experiences…it motivates us at the same time, you know? 'Cause it’s like difficulties make you wanna do better.” (B3F2)	“I definitely take my failures as lessons, um, in how to cope with, like, struggles and issues at both home and school. I just think of my family and the struggles we go through. And that just motivates me.” (A5M1)
Asking for help	“I was just one of those people who’s like, if I don’t understand it, I’ll try and figure it out on my own, because I don’t want to be that person who is always asking questions, you know, and I-- until I realized that once you actually ask questions, people, like, actually help you, and it’s not as bad as you think it would be.” (F3F1)	“My school is a predominately Asian school. I was always the only… black person in the room. What would they think of me for giving up, for everyone, every person of color? If I give up on this, what else am I going to give up on?... So, I just worked with my time; and I studied. I got free tutoring and ended up not switching out of the class.” (E1F2)

^a<4 on a five-point Likert scale

^b≥4 on a five-point Likert scale

Emotional self-efficacy.

Students in both high and low emotional self-efficacy groups stressed the importance of redirecting stress and anxiety into focus for achieving goals (Table 4). On multiple occasions, students also noted awareness of transient emotions and the need to compartmentalize to accomplish goals. Students also discussed the need to take a step back from emotionally charged situations in an attempt to understand what is happening objectively and analytically.

Table 4.

Emotional Self-Efficacy Joint Display with Qualitative and Quantitative Results

Qualitative Themes	Lowa Emotional Self-Efficacy n=25 (80.6%)	Highb Emotional Self-Efficacy n=26 (19.4%)
Fulfillment in academic challenges	“I would cry over [that class], and I was stressed over it. It was just really hard, and I never wanted to go to the class. But seeing the end result, being so rewarding really motivated me to continue with AP classes and other honors classes.” (F1F1)	“So how SMASH has helped me is e-every time I’m here, I feel like I’m getting challenged. I’m really happy. Like, it actually makes me think. I’m not finishing in five minutes. I’m finishing in an hour. But I feel more accomplished in the end. (A3F1)
Focus on future goals	“I’ve learned to keep the pressure on myself, ‘cause I know that if I don’t, I’m gonna start slacking off." (F4M2)	“I expect really high of myself sometimes. I try getting [to be] the best I am, but sometimes I know I’m not gonna be able to reach it. So I have to be nicer to myself I would have to say ‘Okay. I didn’t pass this thing, but I can always try again or like retake it.’.” (E4F1)
Fail forward	“I just got tired of being so frustrated with myself. I was like, ‘Okay. Honestly, me being frustrated isn’t helping me have a better grade in this class. So, I have to suck it up and actually do my best and just, like, focus on the class instead of focusing on what I might have not learned or the problems in the past. I have to focus on what I can do to make my future better from the past.’” (B2F1)	“I didn’t wanna accept the fact that I couldn’t do it… I know I ultimately can do it. I just wasn’t ready. I needed to go back, get better, then I will be able to do it. It’s just a growth mindset.”(D1M1)
Asking for help	“I think one of the things that I didn’t do well was simply asking the instructor. ’Cause even though they’re college instructors, our classes are still pretty small, and she has office hours. I never went to a single office hours ’cause I was scared that you know-- I’m, like, a 15-year-old. And there’s gonna be a bunch of 20-year-olds.” (D3F1)	“You can’t just be like ‘Oh, I need this for college…’ You need to want it for yourself. You can’t just do it because it looks good, because other people are doing it. You have to really want it for yourself to be happy doing it.” (B5F1)

^a<4 on a five-point Likert scale

^b≥4 on a five-point Likert scale

Discussion

Lack of diversity in the physician workforce has become an increasingly important topic of discussion within the medical community. Understanding how high school students develop and define academic self-efficacy beliefs may help to clarify what drives them and enables them to pursue advanced degrees and ultimately careers in healthcare. When we compared students across high and low academic self-efficacy survey scores, we saw stark contrasts between how they discussed self-efficacy. Those with higher academic self-efficacy were more likely to describe translating challenges into action, for example by finding the confidence to ask for help and through the development of coping mechanisms. Similarly, students in the high social self-efficacy group described more concrete insights and practices for managing social challenges than their counterparts, although similar challenges were experiences across social self-efficacy groups.

Sense of belonging

While participants in our study appreciated the exposure to providers and healthcare career options, they expressed discouragement by limited URM representation and the absence of people like themselves specifically in medical school. Previous work has shown broadly that a sense of belonging or alignment with the “community of practice” is critically important and yet pervasively absent among URM scientists.⁸ In a qualitative study of barriers to success among URM nursing students, many respondents cited feelings of loneliness and isolation in academia.²³ They discussed feeling “othered” because, unlike most of their White counterparts, several were the first in their families to attend college and had to balance culturally-driven obligations to support family while managing academic coursework.

While a sense of belonging related to financial status may be common to many students irrespective of race or ethnicity, our previous work demonstrated that, when specifically asked about barriers to pursing a healthcare career, URM high school students prioritized financial burden and years of education.¹¹ Moreover, Black, Latino, and American Indian students are not only more likely to have educational debt than White and Asian students, the same debt has a disproportionate effect on family finances due to less wealth and other financial resources among minority families.²⁴

Self-Efficacy

Despite these barriers, our findings support the notion that students who have high academic self-efficacy also possess strategies and tools for academic success. Foundational work in self-efficacy holds that an individual’s perceived self-efficacy plays the most important role in career choice – trumping socioeconomic status and parental self-efficacy.²⁵ Additionally, previous work found that students work harder and persist longer if they believe they are capable of achieving academic goals, regardless of prior academic achievement.²⁶ It is plausible that high academic self-efficacy might lead individuals to set ambitious academic goals such as a 4.0 GPA or a competitive MCAT score.

The majority of students placed in the “low” emotional self-efficacy group based on Likert scale responses (Table 1). Rather than attributing this to disproportionately low emotional self-efficacy compared to academic and emotional domains, it is helpful to look at this data in the context of Muris’ original SEQ-C cohort.¹⁴ Students in the original study were recruited from a secondary school and averaged 28.2, 23.6, and 25 for academic, social, and emotional self-efficacy, respectively. Compared to those results, respondents in our study scored significantly higher in academic and social self-efficacy, and slightly higher in emotional self-efficacy. We believe students’ high academic and social self-efficacy scores reflect that of the academic requirements for acceptance into SMASH and family-like environment of a residential program, while their emotional self-efficacy scores are more concordant with the students in the original study.

Resilience

Similar to self-efficacy, grit is described as an individual’s ability to sustain interest and persevere toward long-term goals. Integral to this definition is resilience.²⁸ Based on extensive recent data, resilience has been defined as a “complex and dynamic process describing someone who has the ability to achieve a good outcome in spite of significant adversity or threats that pose risks to normal development and adaptation”.²⁷ Resilience manifests in the presence of both risks and promotive factors such as self-efficacy, competence, and coping skills.²⁹ Some argue that, rather than focusing on mitigating risks, educators and mentors should focus on developing these promotive factors²⁸ and substantial evidence indicates resilience can be developed purposefully. After completion of a resilience-building curriculum that focused on emotion regulation, problem-solving, goal setting, communication, and managing stress, low income racial and ethnic minority students demonstrated improved internal resilience, problem solving, and empathy scores.³⁰ Our results demonstrated the importance of social self-efficacy as it relates to resilience, particularly when confronted with academic hardship. Respondents voiced a near global strategy of learning from academic mistakes and not dwelling on negative emotions associated with failure.

Our study is not without limitations. This is a single-institution study with the limitations inherent to qualitative research including limited sample size. Participants were academically high-achieving and self-enrolled in the program because of their interest in medical school and STEM careers, and therefore our findings should not be expected to represent all URM high school students. Rather than focusing on generalizability, however, we specifically used a qualitative approach to explore self-efficacy as experienced by the range of students who participated. Additionally, the quantitative self-efficacy survey may not measure nuances and other important aspects of self-efficacy outside of those highlighted in the three domains. However, utilizing the convergent mixed methods design, our qualitative findings were able to support the quantitative high and low self-efficacy groups, indicating that the three domains were represented in this study population.

Conclusion

While pursuing a career in surgery is a long and challenging process, this journey presents specific challenges for URM students. Self-efficacy and sense of belonging is key to URM students’ academic success. We found that students’ ratings of academic and social self-efficacy aligned with their descriptions of strategies and concrete behaviors such as asking for help, coping mechanisms, and time management—key skills in pursuit of a surgical career if not all STEM or healthcare-related careers. All students expressed similar academic and career aspirations regardless of survey-based ratings. Efforts to recruit and improve diversity in the surgeon workforce should focus on students’ career aspirations and strategies to support self-efficacy toward their academic success.