A decade ago, the Sullivan Commission Report “Missing Persons: Minorities in the Health Professions” concluded that increasing the diversity of medical students, residents, and faculty is an indispensable tool in efforts to improve access to health care for underserved populations.1 Importantly, African American and Hispanic physicians are more likely to work in underserved and minority communities and to accept Medicaid and uninsured minority patients, providing the underserved with access to care.2 According to the Association of American Medical Colleges (AAMC) Group on Diversity and Inclusion, despite increasing diversity among the physician workforce, there is still a strong lag behind the nation’s diversity, and “although blacks and African Americans comprise 13 percent of the nation, they account for only 4 percent of the physician workforce.”3 Much work remains to be done to align the diversity of the health care workforce with the changing racial and ethnic backgrounds of patients, especially in the field of emergency medicine. According to a recent report by Landry et al,4 in 2013, 17% to 23% of obstetrics–gynecology, family medicine, and pediatric physicians were underrepresented minorities (URMs) compared with 13% of emergency medicine physicians. Their report also stated that “while racial and ethnic minorities considered to be URMs in medicine make up approximately 30% of the total U.S. population … [URMs] only [make up] 6% of all practicing physicians,” 16% of students entering medical school, and 14% of emergency medicine residents.4 As medical safety nets, emergency departments provide care to the most diverse and resource-poor patient populations, but the discipline of emergency medicine is lagging behind in training a diverse physician workforce.
In 2008, the Academic Assembly of the Council of Emergency Medicine Residency Directors (CORD) published a set of best practice recruitment strategies designed to increase the number of URMs in emergency medicine residency programs.5 In a recent unpublished national survey of emergency medicine residency programs investigating the programs’ use of these best practice strategies, Boatright et al found that having higher numbers of URM faculty, being a part of URM pipeline initiatives, and explicitly expressing an interest in applicant diversity were associated with increased recruitment of URM residents. However, to date, only 46% of residency programs have implemented two or more of the recommended best practice strategies for URM recruitment (D. Boatright et al, unpublished data, academic year [AY] 2013).
In AY 2012–2013, the Denver Health Residency in Emergency Medicine program (DHREM) formed a diversity committee to develop a focused pilot intervention to increase the number of URM residency candidates who were interviewed and matched at the DHREM. The DHREM is based at the Denver Health Medical Center (DHMC), a core teaching affiliate of the University of Colorado School of Medicine (SOM). All DHREM program leaders and teachers have full-time faculty appointments at the SOM.
The diversity committee was established by two URM residents and included URM and non-URM faculty, the DHREM director, the academic chair of emergency medicine, the director of emergency medicine, associated DHREM directors, the DHREM coordinator, and current DHREM residents. The diversity committee used the SOM’s current definition of URM, which includes African American/black, Latino/Latina, Native Hawaiian, Native American, and Vietnamese individuals. After extensive discussions and literature reviews, and with financial support from multiple sources (see the disclosures section below), the diversity committee developed a pilot intervention with three principal strategies, based on the 2008 CORD recommendations: (1) the implementation of a scholarship-based externship program; (2) the implementation of a funded second-look event, which occurred in AY 2013–2014, one year after the initial pilot implementation; and (3) increasing the involvement and visibility of URM faculty in the interview and recruitment process. For the first year of the intervention, the specific goals were to double the number of URM applicants interviewed at the DHREM, to match at least two URM residents into the DHREM, and to increase the involvement of URM faculty in the recruitment process. The number of URM candidates interviewed and matched at the DHREM the year of implementation of the second-look event and one year after implementation of the pilot intervention (AY 2013–2014) were measured and compared with two years of preintervention baseline data (AYs 2011–2012 and 2012–2013).
Scholarship-based externship program
The diversity committee created a competitive one-month scholarship-based externship program in AY 2012–2013 to increase URM medical students’ exposure to the DHREM and decrease the costs of rotating at the DHREM. Recipients of the scholarship received $1,500 each to support their travel and housing expenses during their rotation. The scholarship was open to all medical students in the beginning of their fourth year who were interested in caring for the underserved and were not enrolled at the SOM. A select group of residents and faculty evaluated all applications to select those applicants who were most likely to continue with a commitment to caring for the underserved and to be successful in residency. A total of five scholarships were awarded during the first year. During the externship, these students rotated in clinical shifts and were assigned a faculty mentor to guide them in completing a scholarly project. Faculty mentors also served as advocates for their student during the residency selection process.
Funded second-look event
In addition to the scholarship-based externship program, in AY 2013–2014, the diversity committee created a second-look event to fund selected URM candidates to return to Colorado. The costs for nine students (up to $11,090 total) were covered to pay for flights and hotels, enabling the students to participate in two days of activities, including introductions to URM faculty members, presentations regarding global health programs, procedure labs, a breakfast with current residents, and a mixer with diverse health care community representatives. There was also a dinner at the DHMC with participation from keynote speakers, including the director of emergency medicine, the academic chair of emergency medicine, the DHREM director, the chief executive officer of the DHMC, and the mayor of Denver, Colorado. The dinner was an interdepartmental event that also included the internal medicine and pediatrics departments and their targeted second-look students. The second-look event activities were designed to help students familiarize themselves with DHREM research and teaching efforts, immerse themselves in the local community, and foster connections with the diverse faculty and community leaders.
Increasing the involvement and visibility of URM faculty in the residency interview and recruitment process
The diversity committee also increased the involvement and visibility of URM faculty, as well as other faculty members who view diversity in medicine as important, in the residency interview and recruitment process in AY 2012–2013. Faculty mentors and members of the diversity committee who had close contact with the externs wrote letters of support or were present during meetings where the ranking of DHREM candidates was discussed prior to matching. In addition, one member of the diversity committee wrote letters of evaluation for externs to add to their residency applications. Finally, all residency applications from self-identified URM candidates were reviewed by members of the diversity committee first, with targeted follow-up and meetings during candidates’ interview days. Targeted follow-up included follow-up phone calls, prompt interview invitations, and suggestions to interview early in the season, which were key in increasing the number of URMs interviewed at the DHREM.
Of note, during the implementation of the pilot intervention, there was little change in the diversity of the emergency medicine faculty: In 2011, there were five URM faculty members, and at the end of 2012, there were six.
One year after the implementation of the pilot intervention, the percentage of URMs among all applicants invited to interview at the DHREM doubled (7.1% [20/282] in AY 2011–2012, 7.0% [24/344] in AY 2012–2013, and 14.8% [58/393] in AY 2013–2014) (95% confidence interval [CI] = 5–10, 4–11, and 11–19, respectively). Of all DHREM interviewees in AY 2013–2014, 17.6% (49/279) (95% CI = 12–23) were URMs, nearly a threefold increase compared with AY 2012–2013 (6.2% [14/226], 95% CI = 3–10). In AY 2013–2014, 23.5% (4/17) (95% CI = 7–50) of all new DHREM residents were URMs compared with 5.9% (1/17) in AY 2011–2012 and 5.6% (1/18) in AY 2012–2013 (95% CI = 0–29 and 0–27, respectively), a fourfold increase (Figure 1). Though the number of total applicants and URM applicants both rose during this time, the percentages of URMs interviewed and matched at the DHREM were far greater than in previous years (Figures 1 and 2). All four URM applicants that matched at the DHREM in 2014 explicitly stated that they chose the program because of their involvement with the externship program or second-look event. The URMs matched at the DHREM in 2014 included two Native American students, one African American/black student, and one Latino/Latina student. Of note, a fifth applicant that matched at the DHREM self-identified as LGBTQI (lesbian, gay, bisexual, transgender, queer/questioning, intersex), which our residency has identified as an underrepresented group, but which is not currently reported as a URM at the SOM.
Many program directors surveyed by D. Boatright et al (unpublished data, AY 2013) remarked that a major barrier to increasing diversity in emergency medicine residencies is the small pool of qualified URM applicants. However, an increase in the number of URMs on the DHREM ranking list suggests that the pipeline of URMs has increased. In AY 2013–2014, 38 of the top 100 candidates ranked by the DHREM were URMs (with 4 URMs in the top 10); there were only 12 to 14 URMs ranked in the top 100 in each of the previous two years. This increase demonstrates that the applicant pool for the DHREM may be three times larger than previously thought. These 38 URM applicants were ranked highly by the residency selection committee because they were highly qualified: The selection committee did not modify any criteria for ranking applicants, including minimums or weighting factors for grade point averages, board scores, interviews, or applicants’ experiences. However, the cutoff for composite scores was uniformly lowered for all applicants to allow for an increase in the total number of applicants interviewed. Although this change was implemented for all applicants, it did lead to an increase in the number of URM applicants interviewed.
There are several limitations to this study. First, the data reported here only reflect one year of resident recruitment at a single residency program. It is not known whether the positive results will be sustained in future years or whether this intervention’s success would be applicable to other residency training programs in emergency medicine or other specialties. Also, it is not certain whether the intervention’s three strategies described here were solely responsible for the successful recruitment of URM residents; other factors (e.g., temporal trends, the efforts of other residents or faculty members, or changes in the qualifications or personal characteristics of the applicants) may have been influential. Other biases and cointerventions also may have contributed to the intervention’s success. For example, many of the diversity committee leaders, including several of the authors of this paper, participated in the interviews and other recruitment activities, possibly introducing bias in favor of URM candidates. Finally, we do not have survey or other information to help identify which of the three principal strategies were the most important in increasing URM applicants’ interest in the DHREM.
Additional studies are needed to deter mine whether the results of this pilot intervention are sustainable and whether they are generalizable to other residency programs in emergency medicine and other specialties. Surveys may also help to clarify which of the three principal strategies are most effective in increasing the URM pipeline and whether other outreach or recruitment interventions should be considered. In the future, the intervention will expand to emphasize (1) developing strong mentoring programs, pipeline initiatives, and community education activities focusing on careers in medicine; (2) creating a robust interdisciplinary mentoring program to increase professional support for young URM emergency medicine physicians; (3) collaborating with other specialties to replicate this program and its outcomes, so that the field of medicine as a whole becomes more diverse; and (4) becoming more involved in the SOM’s high school and college pipeline programs and School Admissions Committee, where the recruitment of URMs to the health professions really begins. In a 2009 AAMC publication outlining targeted interventions to address racial disparities in health care, the first recommendation was to “increase the racial and ethnic diversity of the U.S. physician workforce,” by increasing the pipeline to medical school.6 The pilot intervention described here, along with early pipeline activities, strong mentorship programs, research opportunities, and efforts to increase staff and faculty diversity, may be a promising approach for increasing diversity in emergency medicine and other residencies, so that our educational, patient care, and community service goals can be achieved.
Of note, after the writing of this Innovation Report, data for AY 2014–2015 became available; in AY 2014–2015, 41.2% (7/17) of all new DHREM residents were URMs, demonstrating a consistent increase in URMs matching at the DHREM two data years after the implementation of the initial pilot intervention.
Acknowledgments: The authors wish to thank the Department of Emergency Medicine at the University of Colorado School of Medicine, Denver Health, and the University of Colorado Hospital, as well as the Denver Health Residency in Emergency Medicine for their support in the creation and success of this program.
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6. Association of American Medical Colleges. Addressing racial disparities in health care: A targeted action plan for academic medical centers. 2009. https://members.aamc.org/eweb/upload/Addressing%20Racial%20Disparaties.pdf
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