What do you believe to be some of the most pressing health issues today?
Would-be physicians who identify as nonwhite -- and whose relatives may suffer from preventable chronic illnesses that disproportionately affect nonwhite populations(report.nih.gov) -- may not offer a typical answer, though.
Prospective medical students might also be asked, What do you do for fun? And those from disadvantaged backgrounds likely won't list the same pastimes as their peers from more prosperous ZIP codes.
Learning to recognize bias in boilerplate queries such as these, which are echoed throughout the journey from undergraduate student to primary care physician, is just one of many adjustments required to arrive at a diverse medical workforce. And although barriers might be daunting, AAFP policy points out that "recruiting and retaining culturally diverse individuals into the field of family medicine is an important strategy to reduce disparities in health outcomes."
Now, a recently published report from the largest safety-net hospital in New England shows that diversity is a variable that can be positively modified with surprising speed.
- A report published in Family Medicine documents an increase in the number of underrepresented minority physicians recruited to the Boston Medical Center Family Medicine Residency Program.
- Co-author Maria Harsha Wusu, M.D., M.S.Ed., told AAFP News that programs wanting to increase diversity "don't have to start from scratch."
- Wusu outlined key interventions that helped increase diversity, even though "the pipeline did not starkly change."
Recognizing that racial and ethnic diversity among family physicians lags behind that of the general population, wrote the authors, "the Boston Medical Center Family Medicine Residency Program developed, implemented and evaluated a strategic plan for diversity recruitment."
The result -- according to "Matching Our Mission: A Strategic Plan to Create a Diverse Family Medicine Residency,"(journals.stfm.org) published in the January issue of Family Medicine -- was a statistically significant increase in the number of underrepresented minority (URM) physicians.
The study was sparked by the observation of family physician and corresponding author Maria Harsha Wusu, M.D., M.S.Ed., of Stanford, Calif., that none of the 10 interns the 2014 National Resident Matching Program placed with the residency identified as a URM physician. So, she met with program leaders, and soon, development, implementation and evaluation of a strategic plan for diversity recruitment were underway.
"My personal passion aligned at a time when the leadership in our program was invested and the institutional mission was ready," Wusu told AAFP News.
With the results now published, she added, the idea now is "to center a conversation on work that can be done to increase diversity, and let people know they don't have to start from scratch."
Wusu and her residency program colleagues began altering their recruitment aims in academic year 2014-2015, knowing that having more URM physicians means better access and quality of care,(www.sciencedirect.com) and that these physicians are more likely to practice primary care(www.ncbi.nlm.nih.gov) and work in underserved communities.(jamanetwork.com)
From 2014 to 2017, the residency increased outreach to URM physicians, revised interview protocols to minimize bias and analyzed recruitment data.
Evaluating recruitment from 2010 to 2017, authors found the percentage of applications by URM physicians rose from 13.3 percent (29 of 218 applicants) to 27.3 percent (110 of 402 applicants). The match rate for URM physicians rose from zero to 20 percent in the three years before the intervention to 50 percent in 2016 and 25 percent in 2017.
The authors called for additional research to verify whether the interventions they employed can yield similar results in other residency programs. Wusu identified several key factors that appeared to play a role.
Naming a dedicated diversity director: In academic year 2016-2017, the authors wrote, a new position of director of diversity programs was created, a 20-percent full-time equivalent administrative role for a faculty member with "demonstrated interest and experience" in diversity recruitment.
Wusu filled the position first when she graduated from residency. The authors wrote that the protected time and compensation were crucial to the outcomes.
"If you are committed to diversity and equity," Wusu explained, "you need to devote resources to it, just as you'd have someone in charge of clinical rotations."
Looking outside medicine for innovations: Wusu said important ideas came from nonmedical sources, including the Harvard Business Review.
"In working out strategies around diversity recruitment, a lot of the helpful practices come from business literature," she said. "Some large global brands are ahead of where the medical community is in terms of diversity benefits."
Conducting blind structured interviews and using standardized questions: Starting in academic year 2015-2016, two of the four interviews conducted with program candidates (excluding those with the program director, but including one of two with faculty and a resident) were blinded -- meaning the interviewer had no access to the candidate's academic record.
"This helps eliminate the halo effect, in which the interviewer's preconceptions based on scores influence the interview evaluation," the authors wrote, citing evidence indicating(insights.ovid.com) that URM physicians "traditionally score lower on the National Board of Medical Examiners examinations."
In the 2016-2017 academic year, the researchers continued blind interviews with standardized questions "reflecting the program's mission and the characteristics valued in residents" asked in a structured order. (The authors noted that the Association of American Medical Colleges recommends structured interviews.)(www.aamc.org)
In-house support: Each recruitment season during the intervention began with a faculty development workshop and a resident meeting that explained the reasoning behind the interventions.
"Whenever there is a big change, which recruitment was, you're always going to get questioning or challenging," Wusu said. "But the thing that helped us through that was showing the evidence that tied a more diverse physician workforce to improved patient outcomes."
An important aspect of this in-house support was the effort to limit the extra responsibilities placed on URM physicians in academic medicine, particularly related to diversity -- a burden other researchers have called the "minority tax" -- by having non-URM faculty assist in developing the new processes. Participation of URM residents and faculty in additional recruitment activities, the authors wrote, "was presented as optional rather than an expectation."
Finding Underrepresented Applicants
Wusu acknowledged that non-safety-net institutions and rural programs may move more slowly toward greater diversity.
"When we did background research, one of the biggest barriers we saw was geographic location. People not from Boston were hesitant to come to Boston, for instance."
And nationwide, she added, diversity is a pipeline issue.
"I think some of the pushback or questioning, particularly at the GME (graduate medical education) level, is: Where will these physicians of color come from? There just aren't enough medical students," Wusu said. "Definitely the root cause of the problem is with other inequities, our country's history of racism. We see it in education broadly and in medical education. But I don't think we need to wait for larger numbers in the pipeline to think about our own processes. For us, the pipeline did not starkly change. What did change was the way we recruited and evaluated applicants when we had diversity as a core goal.
"The whole conversation is different now, and there's a different expectation about how our residents reflect the patient population," she said. "I hear from a lot of residents that, when they go to our website as an applicant and see the faces of residents and see faces of color, they see a program's dedication to having a representative residency."
Related AAFP News Coverage
New Research Examines Diversity in Family Medicine
Despite Progress, Workforce Still Lags