Despite decades-old calls for increased racial and ethnic diversity in academic medicine, the number of minority faculty physicians remains extremely low. In 2015, the latest year for which data are available, African Americans constituted 3%, and Latinos/Hispanics 4%, of full-time U.S. medical school faculty1 despite representing, respectively, 13.3% and 17.6% of the U.S. population.2 Much more needs to be done to encourage and support minority medical students, residents, and fellows who want to pursue careers in academic medicine.
Students from groups underrepresented in medicine (URM) enter medical school with the intent of pursuing academic careers in similar (Latino) or only slightly reduced (African American) proportions as their white counterparts3; however, fewer URM students indicate the same intent upon graduation from medical school or residency—even when they have considerable experience with research.3,4 Early academic experiences appear to strongly influence career choice, and early negative experiences in research may be particularly harmful to the academic career development of URM students.4–7 Conversely, multiple studies of URM and women medical students, fellows, and faculty indicate that the path to a career in academic medicine is more easily navigable with appropriate mentoring and with targeted social support that eases ongoing stress and helps scholars overcome hurdles.7–14
In 2012, a group of educators at the University of California, San Francisco (UCSF) developed an innovative program with the goal of increasing interest in research and academic careers among URM medical students. Called “Promoting Research Opportunities Fully—Prospective Academics Transforming Health” (PROF-PATH), the program, funded via a National Institutes of Health (NIH) grant (NIMHD R25MD006832), applies social cognitive career theory (SCCT) to medical student research training. SCCT posits that career-related interests, goals, and choices develop from an individual’s self-efficacy and outcome expectations.15 UCSF’s PROF-PATH program is designed to provide additional mentoring and training to supplement the traditional research program (TRP) at UCSF and, specifically, to enhance student self-efficacy in research. Like the TRP, PROF-PATH provides funds for students who undertake mentored research experiences—either a summer program for students between years 1 and 2 of medical school or a yearlong fellowship for students between years 3 and 4 of medical school. Elements distinguishing PROF-PATH from the TRP include individual mentorship with PROF-PATH faculty and the Careers-in-Progress (CIP) curriculum (see Table 1). Supplemental Digital Appendix 1, available at https://links.lww.com/ACADMED/A673, provides a table comparing the summer PROF-PATH program, the yearlong PROF-PATH program, and the summer TRP program.
;)
Table 1: PROF-PATH Careers in Progress Weekly Curriculum Overviewa
The two-hour CIP sessions meet weekly during the summer for all PROF-PATH students (both summer and yearlong) and monthly during the rest of the year for students in the PROF-PATH yearlong fellowship program. The sessions are designed to enhance academic skills, buttress resilience in academic pursuits, and increase emotional competence (which Gardner16 defines as the social and emotional skills required to coordinate feelings, thinking, and good judgment with a view to short- and long-term outcomes). Another important goal of the CIP sessions is to create and support PROF-PATH participants’ emerging physician–researcher identity. The overarching intent of PROF-PATH is to create a tailored and supportive learning environment replete with appropriate role models and social networking opportunities. PROF-PATH emphasizes both (1) the “missing curriculum”17 (i.e., assumed knowledge) in academia, which includes topics such as the importance of authorship order, and (2) anticipatory guidance focused on challenges frequently encountered in research (e.g., a mentor too busy to supply guidance).
We evaluated PROF-PATH’s influence on participants’ career-related goals, interests, and choices using a mixed-methods approach. Rather than relying on an isolated pre–post evaluation of students in PROF-PATH alone, we conducted a survey to compare the experiences of PROF-PATH participants with those of TRP participants to discern whether PROF-PATH offered any additional value. We also used qualitative methods to investigate PROF-PATH participants’ perceptions of the program. We then analyzed how PROF-PATH had affected participants and examined whether those effects mapped onto the theoretical constructs of SCCT.
Method
Participants and programs
Students were selected, based on their application (as outlined here), for a summer or yearlong mentored research experience in either the PROF-PATH or TRP program. Students underwent a competitive application process that required them to submit a short statement of research interest, a three-page description of their proposed research project, and a mentor’s endorsement that included both information on the mentor’s past experiences (e.g., a biosketch) and answers to closed-ended questions on mentor availability and resources. Two faculty members independently reviewed and scored each application, and then a faculty committee reviewed all applications, choosing participants for all three programs based on their application scores. Participants were selected for the supplementary PROF-PATH program based on their eligibility and interest. Eligibility criteria for PROF-PATH participation were as follows (1) status as a person from a disadvantaged group or a group URM, as defined by NIH criteria18; or (2) for students from any background, a health disparities–focused research project. Students reviewed the PROF-PATH eligibility criteria and program description and indicated if they were interested in PROF-PATH when they applied for the summer or yearlong research program (typically the spring before enrolling in the program).
The TRP consisted primarily of funding for summer students and funding plus occasional research works-in-progress (WIP) sessions for yearlong students; it had no associated curriculum. Both TRP and PROF-PATH students received mentoring as they worked on research projects. Project research mentors for TRP and PROF-PATH participants were full-time UCSF faculty members from diverse disciplines who had accepted voluntary research mentoring responsibilities for students. PROF-PATH was an additive program: Participants received the same amount of funding and participated in the same WIP sessions as the TRP program students. They received additional mentorship and teaching from PROF-PATH faculty. The additional mentorship was provided through both the PROF-PATH-specific CIP curriculum, which included weekly two-hour workshops, and three to four ad hoc, one-on-one meetings with PROF-PATH faculty (see Table 1). PROF-PATH faculty mentoring focused on the experience of conducting research; the specifics of the research project were in the domain of their primary research mentors. PROF-PATH faculty consisted of three URM senior faculty members (A.F., L.F., and A.M.) with expertise in, collectively, research training, career development, and emotional intelligence skills development.
Student surveys
We administered electronic surveys to all students who had participated in either PROF-PATH or TRP between 2013 and 2016 (version XM; Qualtrics, Provo, Utah; 2013). See Supplemental Digital Appendix 2, available at https://links.lww.com/ACADMED/A674, for the survey. Students received the survey before participating in the program (at which point they had identified and worked with a mentor to submit a research proposal) and a second survey within a month of completing the program. Starting in 2014, pre- and postprogram surveys were linked through an individual anonymous code. In addition to student demographic information, the survey asked students to report their level of self-confidence with skills and abilities useful in a research endeavor (e.g., the ability to find a good mentor). They also reported their level of agreement with statements about career interests and common research challenges (e.g., discussing authorship). Responses consisted of options on a five-point Likert-type scale, ranging from 1 = not at all confident to 5 = extremely confident, or on a Likert scale where 1 = strongly disagree and 5 = strongly agree.
Analysis
We compared preprogram demographic characteristics of PROF-PATH and TRP students using chi-square tests (version 13.1; SAS, Cary, North Carolina; 2013). We separately analyzed (1) differences between PROF-PATH and TRP students’ reported levels of self-confidence and (2) levels of agreement for pre- and postprogram time periods using Wilcoxon rank-sum tests. For a subgroup of students, for whom we had the ability to link pre- and postsurveys (linkage began in 2014), we calculated the change in levels of self-confidence and agreement after participating in the program. For this subgroup of students, we performed Wilcoxon rank-sum tests to compare the change differences between the PROF-PATH students and TRP students, and we used Wilcoxon signed-rank tests to evaluate differences in pre- versus postsurvey responses for PROF-PATH and TRP students. We applied Wilcoxon rank-sum tests and Wilcoxon signed-rank tests because distributions of survey response variables were not normally distributed. Additionally, Wilcoxon signed-rank tests allowed us to perform analyses of matched pairs. All reported P values were two sided, and we considered P to be significant at the < .005 level.
Qualitative investigation
Qualitative evaluation consisted of required focus groups for all PROF-PATH students (n = 85)—as well as additional one-on-one semistructured interviews at the end of their research year for yearlong PROF-PATH students (n = 25). Each focus group or interview was conducted by one of three master’s- or PhD-level evaluators contracted for that purpose; these evaluators were not part of the core program faculty or study. We constructed interview and focus-group prompts based on the program’s curricular components, conceptual framework, and goals. The questions explored students’ perceptions of program strengths, weaknesses, gaps, and unique contributions to their education and professional development. Open-ended questions allowed students to introduce other topics and concerns. Focus groups and interviews were audiotaped and transcribed into documents that constituted the qualitative research data. Focus-group attendees were randomly assigned numbers and deidentified, and the transcripts included only respondent numbers. Transcript files of individual interviews with yearlong students were deidentified and scrambled by academic year. See Supplemental Digital Appendix 3 and Supplemental Digital Appendix 4 at https://links.lww.com/ACADMED/A675 for, respectively, focus-group and interview guides.
Two of us (L.A. and V.C.) who did not serve as program mentors used directed content analysis,19 as well as procedures including open and axial coding, constant comparison, and theoretical saturation, to analyze the qualitative data.20 We extracted themes from the data, grouped them by general category, mapped them onto key components of SCCT, and selected representative quotes for each component. Next, we submitted the thematic categories, mapping, and quotes to three additional investigators (A.F., A.M., L.F.) for critique. We resolved differences of opinion by consensus.
The institutional review board at UCSF approved the study procedures.
Results
Survey results
Of the 454 eligible students, 343 (75.6%) completed the survey, and of these 85 (24.7%) participated in PROF-PATH and 258 (75.2%) in the TRP. Compared with TRP students, more PROF-PATH students identified as Latino (44.7% [38/85] vs 7.0% [18/258], P < .0001) or African American (21.2% [18/85] vs 3.5% [9/258], P < .0001). Fewer PROF-PATH students compared with TRP students identified as Asian (18.8% [16/85] vs 39.1% [101/258], P < .0001) or white (28.2% [24/85] vs 51.6% [133/258], P = .0002). In the presurvey, while PROF-PATH and TRP students reported similar amounts of prior research experience (with about half reporting no, little, or some prior experience), far fewer PROF-PATH students reported having coauthored a research paper (38.8% [33/85] vs 62.8% [162/258], P = .0001). See also Table 2.
Table 2: Characteristics of PROF-PATH and Traditional Research Program Students, 2013–2016
Before participating in the research career development program, both PROF-PATH and TRP students expressed similar degrees of confidence in their ability to choose a career that fits their interests, be successful in an academic career, manage professional challenges, and effectively showcase themselves professionally (Table 3). According to the preprogram surveys, PROF-PATH students were somewhat less confident than their TRP peers in their ability to find good mentors (mean score: 3.36 vs 3.60, P = .02), manage the relationship with their mentors (3.42 vs 3.72, P = .006), and effectively describe their research (3.59 vs 3.83, P = .02). PROF-PATH students also indicated lower agreement that they planned to pursue an academic career (3.35 vs 3.55, P = .04). Additionally, the TRP and PROF-PATH students perceived similar levels of institutional support for their research, but the PROF-PATH students reported less agreement on having a mentor who provided strong support for their research interests (3.47 vs 3.90, P = .0008). Finally, while TRP and PROF-PATH students reported having discussed authorship with their mentor at similar rates in the preprogram survey, PROF-PATH students reported less agreement on understanding the rules of authorship (3.19 vs 3.57, P = .007) and on the various ways to disseminate research findings (3.06 vs 3.47, P = .002).
Table 3: PROF-PATH and TRP Students’ Pre- and Postprogram Confidence in and Experience With Academic Career Skills (2013–2016)a
After completing the program, PROF-PATH and TRP students were similarly confident in their skills and abilities, except that PROF-PATH students reported greater confidence (4.08 vs 3.83, P = .009) in managing professional challenges. PROF-PATH students were, at the end of the research mentor program, similar to TRP students in reporting plans to pursue an academic career (3.59 vs 3.58, P = .71). Compared with their TRP peers, PROF-PATH students also reported stronger agreement with statements about adequate support from the institution (4.06 vs 3.72, P = .03), understanding authorship (4.48 vs 3.90, P < .0001), discussing authorship with mentors (4.44 vs 3.74, P < .0001), and understanding ways to disseminate research (4.34 vs 3.81, P < .0001). The two groups were similar in their agreement with statements about support from their mentors and in their ability to communicate their needs to their mentors (Table 3).
Examination of differences in score changes among the two groups (cohort years 2014–2016) was possible in the subgroup of students (PROF-PATH = 52; TRP = 179) who had completed linked surveys. (See Supplemental Digital Appendix 5 at https://links.lww.com/ACADMED/A675 for details about this subgroup.) Examination of score changes indicated that PROF-PATH students increased their confidence more than TRP students with respect to finding good mentors, managing their relationships with mentors, and managing professional challenges (Table 4). PROF-PATH students’ agreement that a research or academic career could best leverage their skills and training increased more than that of TRP students. In addition, PROF-PATH students showed greater increases than TRP students in multiple domains of skills and abilities; score changes for PROF-PATH students were closer to 0.6 versus 0.2 for TRP students. PROF-PATH students also reported more institutional and mentor support compared with TRP students. Finally, PROF-PATH students appeared to gain more confidence about authorship conventions and dissemination of research than their TRP counterparts (Table 4).
Table 4: Score Changes From Preprogram to Postprogram on Individual Items for PROF-PATH and TRP Students’ Scores (2014–2016)a
Qualitative results
Of the 85 PROF-PATH students, 74 (87%) participated in the qualitative assessments (9 had scheduling conflicts); all 22 yearlong students participated in individual interviews. The focus groups lasted 45 to 51 minutes, and interviews ran for 27 to 50 minutes.
We identified multiple themes from what participants shared in the focus groups and interviews, and many of these readily mapped onto the seven components of the SCCT model (Table 5). For example, many PROF-PATH students reported that discussion with peers and mentors allowed them to normalize their concerns and insecurities regarding research and thereby gain confidence. This theme mapped well to the SCCT component of self-efficacy. Another example is less positive: Some students felt that their non-URM peers devalued their achievement in being selected for a summer research experience, saying that PROF-PATH was a “minority grant” and hence less prestigious.
Table 5: Student Perceptions of the 2013–2015 UCSF PROF-PATH Program Mapped to the Key Components of SCCTa
Our analysis also identified two themes that did not fit as clearly in the SCCT model but that students consistently identified as important to their professional development. These themes were (1) demystification of assumed knowledge in academic medicine through discussion of often-unmentioned topics (e.g., academic salaries and promotion criteria); and (2) the importance of explicit instruction, including examples, on how to accomplish tasks that are not research per se but are essential for research success (e.g., raising authorship issues and managing one’s mentor). In addition, some summer students struggled with relating the emotional competence component of the CIP sessions to their development as researchers. By contrast, the yearlong students, whose CIP content was more robust, uniformly extolled the utility of the emotional competence component in their work.
Discussion
In this four-year evaluation of an NIH-funded research and academic career development program for URM medical students and students interested in health disparities research, we found that after participating, PROF-PATH students reported similar or greater confidence in their research abilities and similar intent to pursue a research career compared with their largely non-URM counterparts who participated in a TRP. Overall, student self-efficacy in research increased more for PROF-PATH students than for TRP students.
PROF-PATH and TRP students differed at baseline in two ways. Compared with TRP students, PROF-PATH students were predominantly URM, reflecting the program’s goals to recruit URM students and non-URM students working in health disparities research. PROF-PATH students also reported fewer prior publications than TRP students despite reporting similar amounts of prior research experience. Research in other fields indicates that racial/ethnic differences occur in publication experience,21 perhaps because of subtle differences in opportunities. By the end of the program, however, PROF-PATH students scored higher than TRP students in statements about understanding rules of authorship, understanding ways to disseminate scholarship, and, most important, having discussed authorship, a frequently challenging area, with their mentor. Prior research has highlighted the importance of integrating guidance on authorship into research programs for medical students.22 Our results support this curricular recommendation for research and career development programs for medical students in general, or for those focused on students from URM groups.
Self-efficacy is a key component of SCCT. Through the qualitative component of our investigation, we found that students valued PROF-PATH for multiple reasons consistent with this domain of SCCT. They reported that the program offered vicarious experiences of success via student peers and faculty role models. They reported that the program enabled both their confidence (they were better able to imagine their own success) and their research mastery attainment (they gained and applied skills and knowledge). The program also provided encouragement and guidance in the soft skills necessary for research (e.g., how to discuss their work succinctly and clearly) and in the unwritten rules and knowledge that pervade research and academic medicine, such as the rules of authorship. The resulting increase in self-efficacy should enhance career goal persistence.
PROF-PATH is similar to faculty development programs for URM faculty that provide augmented group and individual mentoring to fellows and junior faculty.23 A randomized trial of one such program for doctoral students found that, after one year, students in the augmented group mentoring program viewed academic careers as more achievable than students randomized to usual dyadic mentoring. The study’s authors highlight the advantages of this group mentoring program, which include providing access to highly experienced faculty who can act as independent advisors and may not be as prone to conflicts of interest as a research project advisor.23 Additionally, the group mentoring program established dedicated time for discussions of academic mores and challenges and provided students with a safe space to discuss sensitive issues, including issues related to minority status.23 This type of program may also offer efficiencies over programs designed to train individual research faculty on cross-cultural mentoring.24 Yearlong programs for medical students at NIH have also been found to provide long-term career benefits.25 PROF-PATH, similar to these other programs, represents an example of efficient use of local resources.
PROF-PATH’s program evaluation has several strengths. It examines results over four years and includes data from a substantial number of students. Additionally, it employs both quantitative and qualitative methods to explore program impact, and it employs a robust conceptual framework to understand possible mechanisms for student success. An important limitation is that the long-term effect on student entrance into academic medicine remains to be seen. A second limitation concerns generalizability. Students in this medical school are highly accomplished: 57% report having authored a publication before enrolling in their research program. By contrast, about 42% to 48% of all U.S. medical students (2013–2016) reported authoring a manuscript upon graduation from medical school.26 Thus, the baseline level of knowledge and confidence may not be representative of all medical students, and program outcomes may not generalize to other schools. Finally, we have no data on nonresponse bias. While all the PROF-PATH students participated in the presurvey, we have no information on the characteristics of the TRP students who did not respond to the survey.
PROF-PATH was made possible by external funds that supplemented institutional funds for student research and faculty time. Leaders of medical schools that already have a substantive student research program and who are motivated to increase diversity in academic medicine should consider creating their own version of PROF-PATH. The CIP sessions, the main backbone of the program, can be adapted to all levels of learners and readily taught by experienced faculty at other institutions. Institutional support is key to any program’s success. In our setting, the program had extensive leadership support. As PROF-PATH students noted, however, more needs to be done to change the culture at an institution where a minority program is considered somehow less prestigious.
Diversification of the biomedical research workforce is in the nation’s compelling interest.27 A critical step toward this goal is to support minority medical student interest in research and academic careers. Targeted supplementary mentoring programs, such as the one described here, may play a catalytic role in academic physician diversification.
Acknowledgments:
The authors would like to acknowledge grant support provided through the National Institutes of Health National Institute of Minority Health and Health Disparities, NIMHD R25MD006832.
References
1. Association of American Medical Colleges. Diversity in Medical Education: Facts & Figures, 2016. Percentage of U.S. medical school full-time faculty by race and ethnicity, 2015.
http://www.aamcdiversityfactsandfigures2016.org/report-section/section-3/#figure-20. Accessed February 25, 2019.
2. United States Census Bureau. Population estimates, July 1, 2018.
https://www.census.gov/quickfacts/table/PST045216/00. Accessed February 25, 2019.
3. Association of American Medical Colleges. Diversity in Medical Education: Facts & Figures 2012. 2012. Washington, DC: Association of American Medical Colleges;
https://members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Education%20Facts%20and%20Figures%202012.pdf. Accessed February 25, 2019.
4. Barr DA, Gonzalez ME, Wanat SF. The leaky pipeline: Factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students. Acad Med. 2008;83:503–511.
5. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154–1164.
6. Palepu A, Carr PL, Friedman RH, Ash AS, Moskowitz MA. Specialty choices, compensation, and career satisfaction of underrepresented minority faculty in academic medicine. Acad Med. 2000;75:157–160.
7. Sciscione AC, Colmorgen GH, D’Alton ME. Factors affecting fellowship satisfaction, thesis completion, and career direction among maternal–fetal medicine fellows. Obstet Gynecol. 1998;91:1023–1026.
8. Mahoney MR, Wilson E, Odom KL, Flowers L, Adler SR. Minority faculty voices on diversity in academic medicine: Perspectives from one school. Acad Med. 2008;83:781–786.
9. Nunez-Smith M, Curry LA, Bigby J, Berg D, Krumholz HM, Bradley EH. Impact of race on the professional lives of physicians of African descent. Ann Intern Med. 2007;146:45–51.
10. Odom KL, Roberts LM, Johnson RL, Cooper LA. Exploring obstacles to and opportunities for professional success among ethnic minority medical students. Acad Med. 2007;82:146–153.
11. Palepu A, Carr PL, Friedman RH, Amos H, Ash AS, Moskowitz MA. Minority faculty and academic rank in medicine. JAMA. 1998;280:767–771.
12. Palepu A, Friedman RH, Barnett RC, et al. Junior faculty members’ mentoring relationships and their professional development in U.S. medical schools. Acad Med. 1998;73:318–323.
13. Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported experience with racial and ethnic discrimination in academic medicine. J Gen Intern Med. 2004;19:259–265.
14. Price EG, Gozu A, Kern DE, et al. The role of cultural diversity climate in recruitment, promotion, and retention of faculty in academic medicine. J Gen Intern Med. 2005;20:565–571.
15. Lent RW, Brown SD, Hackett G. Toward a unifying social cognitive theory of career and academic interest, choice, and performance. J Vocat Behav. 1994;45:79–122.
16. Gardner H. Frames of Mind: The Theory of Multiple Intelligences. 2011.New York, NY: Basic Books.
17. Flowers LK. The missing curriculum: Experience with emotional competence education and training for premedical and medical students. J Natl Med Assoc. 2005;97:1280–1287.
18. National Institutes of Health, Office of Extramural Research. Diversity matters.
https://extramural-diversity.nih.gov/diversity-matters. Accessed February 25, 2019.
19. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–1288.
20. Strauss A, Corbin J. Basics of Qualitative Research, Techniques and Procedures for Developing Grounded Theory. 1998.2nd ed. Thousand Oaks, CA: Sage Publications, Inc..
21. Mendoza-Denton R, Patt C, Fisher A, et al. Differences in STEM doctoral publication by ethnicity, gender and academic field at a large public research university. PLoS One. 2017;12:e0174296.
22. Karani R, Ognibene FP, Fallar R, Gliatto P. Medical students’ experiences with authorship in biomedical research: A national survey. Acad Med. 2013;88:364–368.
23. Williams SN, Thakore BK, McGee R. Coaching to augment mentoring to achieve faculty diversity: A randomized controlled trial. Acad Med. 2016;91:1128–1135.
24. Gandhi M, Fernandez A, Stoff DM, et al. Development and implementation of a workshop to enhance the effectiveness of mentors working with diverse mentees in HIV research. AIDS Res Hum Retroviruses. 2014;30:730–737.
25. Ognibene FP, Gallin JI, Baum BJ, Wyatt RG, Gottesman MM. Outcomes from the NIH Clinical Research Training Program: A mentored research experience to enhance career development of clinician–scientists. Acad Med. 2016;91:1684–1690.
26. Association of American Medical Colleges. Medical School Graduation Questionnaire: 2017 All Schools Summary Report. July 2017. Washington, DC: Association of American Medical Colleges;
https://www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf. Accessed February 25, 2019.
27. Smedly BD, Stith Butler A, Brsitow LR; Institute of Medicine; Board on Health Sciences Policy; Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce; In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. 2004.Washington, DC: National Academies Press.
