The last post provided an update on our diversity efforts and data at a program level during the 2020-2021 recruitment cycle. I wanted to provide some reflection as we head into the 2021-2022 season, and again emphasize that actions and outcomes matter much more than any words.
I also want to acknowledge that my demographic is part of the problem, and the tension that comes from someone in my position addressing issues like this. What follows may seem hollow to some, and too limited in scope for most. It may even come across as offensive. I profoundly apologize if that is the case, and welcome any criticism. Like last year, these still remain introductory efforts in striving for equity.
Pipeline
As demonstrated in the data from the last post, our applicant pool is limited from a diversity perspective; we need broader representation in ophthalmology resident applicants, but further, in medical school admissions. The documentary and associated movement Black Men in White Coats provides an enlightening perspective on this issue and efforts to change the trajectory.
Some of the most substantial barriers are systematic, such as the cost of medical school. According to the AAMC, roughly ¾ of medical students come from the top two household income quintiles, a statistic that has not changed in the past three decades. This left several experts and advocates to conclude in the New England Journal of Medicine: “… as long as wealth and financial disparities among racial and ethnic groups exist, a truly diverse physician workforce will be achieved only if steps are taken to mitigate the effects of the economic disparities in question.”
But, besides advocacy, what meaningful steps are we taking to improve our pipeline at a program level? We are starting to – limitedly – get involved in local grass roots efforts such as Black Boys and Men in Medicine. We are also involved in local and national DEI academic organizations hoping to address some of these issues.
To try and both increase our awareness and also our presence, we have participated in several outreach efforts including a virtual open house for the UK Chapter of the Student National Medical Association, the Fireside Chat program of the Rabb-Venable Society, and the Minority Ophthalmology Mentoring Program.
Recruitment
Medical student rotators in our department have a much higher historical match rate than other applicants. I imagine this finding is not unique, but as our data from the prior match cycle demonstrates with 90% male and 80% white rotating students, this is an area where increased attentiveness to disparities can potentially lead to change. As a result, the ophthalmology medical student director and myself are both playing a larger role in the selection process. Additionally, we were fortunate to receive philanthropic support to start a scholarship for visiting URM students to help offset some of the costs of travel and living arrangements. We have advertised this scholarship in several locations and hope it will lead to an increase in URM student rotators in the next few years.
As it pertains to recruitment decisions specifically, we previously instituted a mandatory implicit bias training for all faculty involved. We have expanded the curriculum this year and are working with our local GME community to have a more standardized training for all institutional faculty involved in these decisions.
I have increasingly become aware of some of the many biases in recruitment, but not until recently have I even heard of the notion of additional – and perhaps equally important – “noise” in the process. I just finished reading the book Noise: A Flaw in Human Judgment by Nobel Prize winning behavioral psychologist Daniel Kahneman and co-authors. It is worth the read, especially for someone considering a career in medicine. This well substantiated quote alone is worth much circumspection:
“Doctors like to think that they make the same decision whether it’s Monday or Friday or early in the morning or late in the afternoon. But it turns out that what doctors say and do might well depend on how tired they are.”
Without belaboring the point, the authors soundly demonstrate the biases and noise involved in our decision-making process, the concerns with trusting our intuition, and the need to create systems that acknowledge and try to limit their impact. With this and several other things in mind, we have spent the past few years refining our selection process with the following changes:
- Applications are reviewed and scored based on five domains we consider most important in resident performance.
- Interviews are increasingly structured and include standard behavioral questions. Interview performance and scoring is de-emphasized from prior metrics.
- Group discussion about final interview selection and rank list decisions will still occur and is encouraged, but will happen after the standardized process above. The goal is not to entirely remove intuitive judgment, but delay it so we can consider all the evidence as we make the final holistic decision on each applicant.
- The process is continually scrutinized. In particular, we want to ensure the domains we select are truly reflective of our endpoint (residency and career performance), the process itself does not contain systemic biases, and it remains a worthwhile exercise for our faculty (and applicants!).
Support
In 2016, 20% of residents nationwide dismissed from their program were Black. Minority medical students and residents report increased discrimination, micro-aggressions, bias, differing expectations, social isolation, distress, and burnout compared to peers. In a tragic irony, minority students, house staff, and faculty are often required to spend extra time on diversity initiatives, known as the minority tax.
It is imperative that as we expand efforts to increase the pipeline and recruitment of minority residents, we also provide an environment that is welcoming and fosters success. At a minimum, it means that, similar to resident recruitment, we strive and have a faculty and staff that better reflect our community demographics. Unsurprisingly, a recent report found that Ophthalmology faculty are less racially and ethnically diverse than medical students, and further, we have the third lowest proportion of URM faculty compared to other specialties. My sense and hope is this concern is now well established in our academic circles and at the forefront of hiring decisions; it certainly is in our institution. However, given the small applicant pool, niche desires/needs, and many other aspects of faculty recruitment, much needed change takes time. We are encouraged by the increasing diversity in our new faculty and will continue to seek progress.
It also means having faculty that are increasingly aware and receptive to the issues above, many of which all residents face, but our minority ones at an increased and unfortunately often unseen level. These changes come at least in part from education and exposure. As stated before, we have DEI topics built into our grand rounds schedule, but are working towards expansion. Similar to curriculum initiatives in many programs, our goal is to move beyond box-checking to true integration of DEI conversations at all levels of education (classroom to clinic). There is impetus in this direction at our university in general, and the college of medicine and graduate medical education office specifically.
Lastly, we want our applicants to have the opportunity – at least limitedly – to experience our department prior to their selection decision to make sure they feel it can be a supportive environment. This is a primary goal of the URM visiting student scholarship we are sponsoring. I am also very encouraged by the AUPO decision to facilitate post-program rank list open houses, and while the pandemic will likely limit opportunities this recruitment cycle, I am excited to see how it evolves in the future.