michelle ko md phd

Image: Medical schools grapple with upcoming year. MedPage Today. May 9, 2020

Med Twitter is erupting over the administrative debacle of this spring/summer MCAT administration. A group of premedical students, Students for Ethical Admissions, have taken it upon themselves to do the work of collecting and documenting applicants experiences with accommodations, the MCAT, AMCAS and other issues here.  It is worth reading the open-ended comments to see the myriad structural barriers that permeate the entire process of applying to medical school.

As we have seen with UME and GME, there is also a past & present literature on how medical school admissions perpetuates racism within medical education. Few of these studies explicitly call out racism, but together, various examinations of the procedures and metrics show how applicants of color are systematically excluded.

• Chatterjee A, Greif C, Witzburg R, Henault L, Goodell K, Paasche-Orlow MK. US medical school applicant experiences of bias on the interview trail. J Health Care Poor Underserved. 2020;31(1):185-200.
• Lucey CR, Saguil A. The consequences of structural racism on MCAT scores and medical school admissions: The past is prologue. Academic Medicine 95.3 (2020): 351-356.
• Girotti, Jorge A., et al. Investigating group differences in examinees’ preparation for and performance on the new MCAT exam. Academic Medicine 95.3 (2020): 365-374.
• Terregino CA, Saguil A, Price-Johnson T, Anachebe NF, Goodell K. The diversity and success of medical school applicants with scores in the middle third of the MCAT score scale. Acad Med. 2020;95(3):344-350
• Juster FR, Baum RC, Zou C, Risucci D, Ly A, Reiter H, Miller DD, Dore KL. Addressing the diversity–validity dilemma using situational judgment tests. Academic Medicine. 2019. 94 (8 1197-1203
• Harrison LE. Using holistic review to form a diverse interview pool for selection to medical school. Proc (Bayl Univ Med Cent). 2019;32(2):218-221.
• Grabowski CJ. Impact of holistic review on student interview pool diversity. Advances in Health Sciences Education.2018.23.3: 487-498.
• Gay SE, Santen SA, Mangrulkar RS, Sisson TH, Ross PT, Zaidi NLB. The influence of MCAT and GPA preadmission academic metrics on interview scores. Adv Health Sci Educ Theory Pract. 2018;23(1):151-158
• Capers Q 4th, Clinchot D, McDougle L, Greenwald AG. Implicit racial bias in medical school admissions. Acad Med. 2017;92(3):365-369.
• Hadinger MA. Underrepresented Minorities in Medical School Admissions: A Qualitative Study. Teach Learn Med. 2017;29(1):31-41.
• Wright S. Medical school personal statements: a measure of motivation or proxy for cultural privilege?. Adv Health Sci Educ Theory Pract. 2015;20(3):627-643.
• Terregino CA, McConnell M, Reiter HI. The Effect of differential weighting of academics, experiences, and competencies measured by Multiple Mini Interview (MMI) on race and ethnicity of cohorts accepted to one medical school. Acad Med. 2015;90(12):1651-1657
• Garces LM,  Mickey-Pabello D. Racial diversity in the medical profession: The impact of affirmative action bans on underrepresented student of color matriculation in medical schools. 2015.The Journal of Higher Education, 86:2, 264-294
• Ballejos MP, Rhyne RL, Parkes J. Increasing the relative weight of noncognitive admission criteria improves underrepresented minority admission rates to medical school. Teaching and Learning in Medicine. 2015. 27:2, 155-162
• Razack S, et al. Seeking inclusion in an exclusive process: discourses of medical school student selection. Medical education. 2015. 49.1: 36-47.
• Heller CA, Hurtado Rúa S, Mazumdar M, Moon JE, Bardes C, Gotto AM. Diversity efforts, admissions, and national rankings: can we align priorities? Teaching and Learning in Medicine. 2014. 26:3, 304-311
• Davis D, Dorsey JK, Franks RD, Sackett PR, Searcy CA, Zhao X. Do racial and ethnic group differences in performance on the MCAT exam reflect test bias?. Acad Med. 2013;88(5):593-602 (Makes a structural and institutional racism argument…without using those terms)
• Kondo DG, Judd VE. Demographic characteristics of US nedical school admission committees. 2000;284(9):1111–1113. d

One of the strongest signifiers of cultural validity, particularly in more liberal leaning circles, is when NPR covers your story. Which is to say, NPR posted a story today about racism in medical training, so it’s possible that these messages are filtering up to leadership in academic medicine.

To underscore the importance that Anthony Chin-Quee, MD, is far from alone, here is a short collection of evidence on graduate medical education (GME), i.e. residency and fellowship (recent articles, plus a few older to again remind ourselves that we are not discussing a new situation, but one that has been ongoing, i.e. how racism operates).

Martinez-Strengel A, Balasuriya L, Black A, Berg D, Genao I, Gross CP, Keene D, Latimore D, Sotto-Santiago S, Boatright D. Perspectives of internal medicine residency program directors on the Accreditation Council for Graduate Medical Education (ACGME) diversity standards. J Gen Intern Med. 2021 Sep;36(9):2539-2546.

de Bourmont SS, Burra A, Nouri SS, et al. Resident Physician Experiences With and Responses to Biased Patients. JAMA Netw Open. 2020;3(11):e2021769. doi:10.1001/jamanetworkopen.2020.21769

Jarman BT, Borgert AJ, Kallies KJ, et al. Underrepresented minorities in general surgery residency: Analysis of interviewed applicants, residents, and core teaching faculty. J Am Coll Surg. 2020;231(1):54-58. doi:10.1016/j.jamcollsurg.2020.02.042

Williams M, Kim EJ, Pappas K, et al. The impact of United States Medical Licensing Exam (USMLE) step 1 cutoff scores on recruitment of underrepresented minorities in medicine: A retrospective cross-sectional study. Health Sci Rep. 2020;3(2):e2161.

Yuce TK, Turner PL, Glass C, et al. National evaluation of racial/ethnic discrimination in US surgical residency programs. JAMA Surg. 2020;155(6):526-528. doi:10.1001/jamasurg.2020.0260

Dyrbye L, Herrin J, West CP, et al. Association of racial bias with burnout among resident physicians. JAMA Netw Open. 2019;2(7):e197457. doi:10.1001/jamanetworkopen.2019.7457

Jarman BT, Kallies KJ, Joshi ART, et al. Underrepresented minorities are underrepresented among general surgery applicants selected to interview. J Surg Educ. 2019;76(6):e15-e23. doi:10.1016/j.jsurg.2019.05.018 https://pubmed.ncbi.nlm.nih.gov/31175064/

Agawu A, Fahl C, Alexis D, et al. The influence of gender and underrepresented minority status on medical student ranking of residency programs. J Natl Med Assoc. 2019;111(6):665-673. doi:10.1016/j.jnma.2019.09.002

Khan NR, Taylor CM 2nd, Rialon KL. Resident perspectives on the current state of diversity in Graduate Medical Education. J Grad Med Educ. 2019;11(2):241-243. doi:10.4300/JGME-D-19-00062.1

Osseo-Asare A, Balasuriya L, Huot SJ, et al. Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace. JAMA Netw Open. 2018;1(5):e182723. doi:10.1001/jamanetworkopen.2018.2723

Lightfoote JB, Fielding JR, Deville C, et al. Improving diversity, inclusion, and representation in radiology and radiation oncology part 2: challenges and recommendations. J Am Coll Radiol. 2014;11(8):764-770. doi:10.1016/j.jacr.2014.03.008

Yehia BR, Cronholm PF, Wilson N, et al. Mentorship and pursuit of academic medicine careers: a mixed methods study of residents from diverse backgrounds. BMC Med Educ. 2014;14:26. doi:10.1186/1472-6920-14-26

Liebschutz JM, Darko GO, Finley EP, Cawse JM, Bharel M, Orlander JD. In the minority: black physicians in residency and their experiences. J Natl Med Assoc. 2006;98(9):1441-1448. https://pubmed.ncbi.nlm.nih.gov/17019911/

Edmond MB, Deschenes JL, Eckler M, Wenzel RP. Racial bias in using USMLE step 1 scores to grant internal medicine residency interviews. Acad Med. 2001;76(12):1253-1256. doi:10.1097/00001888-200112000-00021

Recommendations:

Gonzaga AMR, Appiah-Pippim J, Onumah C, Yialamas M. A framework for inclusive Graduate Medical Education recruitment strategies: Meeting the ACGME standard for a diverse and inclusive workforce. Acad Med. 2020; 95(5) 710-716 doi: 10.1097/ACM.0000000000003073

Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering systems-based practice: Advancing structural competency, health equity, and social responsibility in Graduate Medical Education. Acad Med. doi: 10.1097/ACM.0000000000003559

p.s. Check out this list for a brief review of undergraduate medical education (UME)

Creator: DKalderon, for OpMed Doximity, ‘This Diversity is Not Real‘

Medicine, and hand-in-hand with it, medical education, have a long history of perpetuating structural and institutional racism, to the direct harm of Black, Indigenous, Latinx and other communities of color.  I wrote about my own experience here.This is only my own personal narrative, whereas there is a growing body of research evidence that illustrates racism in medical education occurs across many dimensions, from selective advantages throughout K-12, to college preparation, to admissions processes, during medical school, residency, and among physicians both in- and outside academic medicine.

Below are some – not a literature review- studies on racism in medical school, or what is technically known as “Undergraduate Medical Education,” which were published just in the last few years. I include one from 2007 to remind us all that the passage of time has not led to major improvements.

Finally, it’s important to note that many in academia have  provided guidelines on how to improve diversity in medical schools. Here’s one example that could be adapted to target racial equity (not just “diversity”): Young ME, Thomas A, Varpio L, et al. Facilitating admissions of diverse students: A six-point, evidence-informed framework for pipeline and program development. Perspect Med Educ. 2017;6(2):82-90. doi:10.1007/s40037-017-0341-5

And here’s a set of recommendations for reform of AOA elections: Boatright D, O’Connor PG, E Miller J. Racial Privilege and Medical Student Awards: Addressing Racial Disparities in Alpha Omega Alpha Honor Society Membership. J Gen Intern Med. 2020 Aug 31. doi: 10.1007/s11606-020-06161-x. Epub ahead of print. PMID: 32869203.

Racism in Undergraduate Medical Education

Teshome BG, Desai MM, Gross CP, Hill KA, Li F, Samuels EA, Wong AH, Xu Y, Boatright DH. Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study. BMJ. 2022 Mar 22;376:e065984. doi: 10.1136/bmj-2021-065984. PMID: 35318190; PMCID: PMC8938931.

O’Marr JM, Chan SM, Crawford L, Wong AH, Samuels E, Boatright D. Perceptions on Burnout and the Medical School Learning Environment of Medical Students Who Are Underrepresented in Medicine. JAMA Netw Open. 2022;5(2):e220115. doi:10.1001/jamanetworkopen.2022.0115

Weiss J, Balasuriya L, Cramer LD, Nunez-Smith M, Genao I, Gonzalez-Colaso R, Wong AH, Samuels EA, Latimore D, Boatright D, Sharifi M. Medical Students’ Demographic Characteristics and Their Perceptions of Faculty Role Modeling of Respect for Diversity. JAMA Netw Open. 2021 Jun 1;4(6):e2112795. doi: 10.1001/jamanetworkopen.2021.12795. PMID: 34086032; PMCID: PMC8178710.

Anderson N, Lett E, Asabor EN et al. The Association of Microaggressions with Depressive Symptoms and Institutional Satisfaction Among a National Cohort of Medical Students. JGIM 2021. https://doi.org/10.1007/s11606-021-06786-6

Bullock JL, Lockspeier T, del Pino-Jones A, Richards R, Teherani A, Hauer KE. They don’t see a lot of people my color: A mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020. doi: 10.1097/ACM.0000000000003628

Ackerman-Barger K, Boatright D, Gonzalez-Colaso R, Orozco R, Latimore D. Seeking inclusion excellence: Understanding racial microaggressions as experienced by Underrepresented Medical and Nursing Students. Acad Med. 2020;95(5):758-763. doi:10.1097/ACM.0000000000003077

Hill, Katherine A., et al. Assessment of the prevalence of medical student mistreatment by sex, race/ethnicity, and sexual orientation.” JAMA Internal Medicine. 2020: 653-665. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2761274

Wyatt TR, Rockich-Winston N, Taylor TR, White D. What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine. Acad Med. 2020 Oct;95(10):1587-1593. doi: 10.1097/ACM.0000000000003192. PMID: 32079956.

Low D, Pollack SW, Liao ZC, et al. Racial/Ethnic Disparities in Clinical Grading in Medical School. Teach Learn Med. 2019;31(5):487-496. doi:10.1080/10401334.2019.1597724

Espaillat A, Panna DK, Goede DL, Gurka MJ, Novak MA, Zaidi Z. An exploratory study on microaggressions in medical school: What are they and why should we care?. Perspect Med Educ. 2019;8(3):143-151. doi:10.1007/s40037-019-0516-3

Phelan SM, Burke SE, Cunningham BA, et al. The Effects of Racism in Medical Education on Students’ Decisions to Practice in Underserved or Minority Communities. Acad Med. 2019;94(8):1178-1189. doi:10.1097/ACM.0000000000002719

Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction. Acad Med. 2019;94(4):562-569. doi:10.1097/ACM.0000000000002463

Claridge H, Stone K, Ussher M. The ethnicity attainment gap among medical and biomedical science students: a qualitative study. BMC Med Educ. 2018;18(1):325. Published 2018 Dec 29. doi:10.1186/s12909-018-1426-5

Teherani A, Hauer, K, Fernandez A, King T,  Lucey, C. How small differences in assessed clinical performance amplify to large differences in grades and awards: A cascade with serious consequences for students Underrepresented in Medicine. Acad Med.  93(9): 1286-1292 doi: 10.1097/ACM.0000000000002323

Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A, Moore EZ. Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations. PLoS One. 2017;12(8):e0181659. Published 2017 Aug 9. doi:10.1371/journal.pone.0181659

Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society. JAMA Intern Med. 2017;177(5):659-665. doi:10.1001/jamainternmed.2016.9623

Hardeman RR, Przedworski JM, Burke S, et al. Association Between Perceived Medical School Diversity Climate and Change in Depressive Symptoms Among Medical Students: A Report from the Medical Student CHANGE Study. J Natl Med Assoc. 2016;108(4):225-235. doi:10.1016/j.jnma.2016.08.005

Burgess DJ, Burke SE, Cunningham BA, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016;16(1):254. Published 2016 Sep 29. doi:10.1186/s12909-016-0769-z

van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748-1756. doi:10.1007/s11606-015-3447-7

Ackerman-Barger, Kupiri, Debra Bakerjian, and Darin Latimore. How health professions educators can mitigate underrepresented students’ experiences of marginalization: Stereotype threat, internalized bias, and microaggressions. Journal of Best Practices in Health Professions Diversity 8.2 (2015): 1060-1070.

Sánchez JP, Peters L, Lee-Rey E, et al. Racial and ethnic minority medical students’ perceptions of and interest in careers in academic medicine. Acad Med. 2013;88(9):1299-1307. doi:10.1097/ACM.0b013e31829f87a7

Hung R, McClendon J, Henderson A, Evans Y, Colquitt R, Saha S. Student perspectives on diversity and the cultural climate at a U.S. medical school. Acad Med. 2007;82(2):184-192. doi:10.1097/ACM.0b013e31802d936a