Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs

Abstract

ImportanceClosing the diversity gap is critical to ensure equity in medical education and health care quality. Nevertheless, evidence-based strategies and best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood and underused. To improve the culture of DEI in graduate medical education (GME), in 2020 the Accreditation Council of Graduate Medical Education (ACGME) launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award to recognize exceptional DEI efforts in US residency programs.ObjectiveTo identify strategies and best practices that exemplary US GME programs use to improve DEI.Design and SettingThis qualitative study performed an exploratory content analysis of award applications submitted to the ACGME over 2 cycles in 2020 and 2021, using the constant comparative method. The research team first acknowledged their own biases related to DEI, used caution to not overinterpret the data, and performed several cross-checks during data analysis to ensure confirmability of the results. A preliminary codebook was developed and used during regular adjudication sessions. Disagreements were discussed until agreements were reached.Main Outcomes and MeasuresFoundational (ie, commonly cited, high-impact, and small-effort strategies considered achievable by all programs) and aspirational (ie, potential for high impact but requiring greater effort and investment) DEI strategies used by exemplary GME programs.ResultsThis qualitative study included 29 award applications submitted between August 17, 2020, and January 11, 2022. Strategies spanned the education continuum from premedical students through faculty. Foundational strategies included working with schools, community colleges, and 4-year college campuses; providing structured support for visiting students; mission-driven holistic review for admissions and selection; interviewer trainings on implicit bias mitigation and on how racism and discrimination impact admission processes and advancement; interview-day DEI strategies; inclusive selection and DEI committees; mission statements that include DEI; and retention efforts to improve faculty diversity. Aspirational strategies included development of longitudinal bidirectional collaborations (eg, articulation agreements, annual workshops, funded rotations and/or research) with organizations working with applicants who were historically excluded and underrepresented in medicine, blinding metrics in residency applications, longitudinal curricula on DEI and health equity, and faculty mentoring such as affinity groups, mentored research, and joint academic-community recruitments. Findings provide residency program leadership with a menu of options at various inflection points to foster DEI within their programs.Conclusions and RelevanceThe findings of this qualitative study suggest that GME programs might adopt strategies of exemplary programs to improve DEI in residency, ensure compliance with accreditation standards, and improve health outcomes for all.

Racial, Ethnic, and Sex Diversity Trends in Health Professions Programs From Applicants to Graduates

“…Although the LCME’s 2009 diversity standards coincided with an increase in female, Black, and Hispanic matriculants, it remains unclear whether this increase was linked to the new standards . The decreasing trend currently seen in medical programs suggests that the LCME standard related to diversity is not sufficient to address the need for more diversity in the health professions programs . For medical programs, low Medical College Admission Test scores, low grade point averages, and poor science preparation have been identified as barriers to pursuing a medical career by premedical students from URM groups and to the recruitment of prospective students from URM groups .…”

“…Myriad efforts have sought to expand the applicant pool and promote equitable recruitment and selection processes, but few have focused on enhancing student inclusion . Research by Nwokolo et al highlights a concerning trend: a widening gap between matriculation and graduation rates for medical students from URM groups.…”

“…Myriad efforts have sought to expand the applicant pool and promote equitable recruitment and selection processes, but few have focused on enhancing student inclusion. 50 Research by Nwokolo et al 54 highlights a concerning trend: a widening gap between matriculation and graduation rates for medical students from URM groups. Contributing factors include academic challenges faced by these students and a stark absence of faculty mentors from URM groups within medical schools.…”

“…42 The decreasing trend currently seen in medical programs suggests that the LCME standard related to diversity is not sufficient to address the need for more diversity in the health professions programs. 50 For medical programs, low Medical College Admission Test scores, low grade point averages, and poor science preparation have been identified as barriers to pursuing a medical career by premedical students from URM groups and to the recruitment of prospective students from URM groups. 51,52 As noted by admissions leaders, the desire for high Medical College Admission Test scores by schools for ranking purposes and using scores for predicting future student success are barriers to efforts to increase diversity in enrollment.…”

Eligible Applicants and Diversity Across Settings in a Regional Family Medicine Residency Network

“… 6 In response, as one part of the solution, increased attention has been given to addressing diversity, equity, and inclusion (DEI) in graduate medical education in recent years. 7 , 8 In 2020 the Accreditation Council for Graduate Medical Education (ACGME) released updated Common Program Requirements, which require all residency programs to address DEI. 9 Many programs are struggling to incorporate the requirement to address DEI; a 2020 survey from the Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity (DHE) Committee indicated that 50% of family medicine program directors were not confident implementing the common program requirement change pertaining to diversity.…”