In this two-part series, we highlight 10 impactful medical education articles presented at the Update in Medical Education during the 2022 Society of General Internal Medicine (SGIM) Annual Meeting. In part one, we summarize studies that identify the status of inequity in various domains in medical education. In part two, we will highlight studies that offer targeted solutions to address racism, lack of diversity and bias in medical school admissions and trainee evaluations, and share innovative approaches to delivering educational content and improving trainee wellness.
Study authors, all members of the SGIM Education Committee, employed a modified Delphi methodology to achieve group consensus on the selection of publications. Studies from a consensus list of journals that regularly publish medical education research were reviewed by the authors (see table). To be included, studies were required to involve internal medicine participants from the United States or Canada, describe original research, and relate to the SGIM 2022 meeting themes (“Discovery, Equity, and Impact”).
In phase one, authors reviewed the table of contents and abstracts of all studies published December 2020-December 2021 in 13 journals. During phase two, authors performed a full-text review of 130 studies identified in phase one. Studies were scored according to the SGIM 2022 National Meeting peer review rubric in the following categories: importance to the audience, soundness of methodology, generalizability of outcomes and relevance to meeting themes. Numerical ratings were aggregated and shared with the group. A subsequent consensus meeting was held to select 10 studies for presentation at the 2022 SGIM Annual meeting. Here, we summarize a subset of those selected publications that highlight the current landscape of racial, gender, and patient equity in medicine to elucidate challenges we face today. This will provide context for the need to address inequities that follow in part two.
Racial Diversity of Faculty, Residents, and Medical Students
Bennet and Ling examined trends in the proportion of U.S. medical school faculty who self-identify as Black by sex, academic rank, and clinical specialty between 1990-2020.1 A slight increase, from 2.68% in 1990 to 3.85% in 2020, in Black faculty representation was seen. While there was a notable increase in Black female faculty representation, from 0.96% in 1990 to 2.32% in 2020, the percentage of Black male faculty decreased by 0.21% between 1990 and 2020. Most Black faculty held the academic rank of assistant professor, which showed the greatest increase over this period (0.89 percentage points).
In our second article highlighted, Bennett, et al, applied logistic regression modeling to examine trends in racial and ethnic diversity of Black and Hispanic resident physicians across the twenty largest medical specialties between 2007-18.2 In 2018, 13.4% and 18.3% of the U.S. population identified as Black and Hispanic, respectively, while the Accreditation Council of Graduate Medical Education (ACGME) trainee population in 2017-18 included only 5.5% who identified as Black and 7.8% as Hispanic, respectively. Only five specialties indicated statistically significant increases from 2007-18. The investigators estimated that if current trends hold, it will take almost a century to achieve proportional Black and Hispanic workforce representation in certain specialties.
A third investigation, Morris et al, examined trends in gender, racial, and ethnic diversity of U.S. medical school enrollees 1978-2019.3 The percentage of women enrollees increased substantially from 24.4% in 1978 to 50.6% in 2019. However, trends again highlighted a decrease in the number of enrollees identifying as Black men (from 3.1% to 2.9%). This study, viewed in combination with those preceding it, suggest that tremendous efforts will be required to build a physician workforce that reflects the population we serve. Action is needed to acknowledge and address the structured biases that have perpetuated the underrepresentation of Black and Hispanic physicians within medicine.
Role Misidentification of Physicians Identifying as Women
Role-based misidentification, a manifestation of gender bias routinely experienced by women physicians, occurs when a physician is mistakenly identified as a non-physician hospital staff member. Berwick et al aimed to quantify the frequency of role-based misidentification in a 2018 cross-sectional survey of resident physicians from three specialties in an academic medical center.4 The authors assessed the frequency as well as participants’ psychological and behavioral response to misidentification events in the preceding inpatient month.
Of 182 respondents, 47% self-identified as women, 72% as White, and 63% were internal medicine residents. 100% of women respondents reported being misidentified (most often as nurses) at least once over the preceding month, compared with 44% of men. Self-assessment of their psychological responses to misidentification showed that 85% of women “felt annoyed” when mischaracterized, 38% “felt angry,” and 36% reported “feeling less satisfied with their jobs.” In response, 51% changed the way they dress, while 81% began emphasizing their title (“Doctor”). Misidentification manifested as requests to complete tasks deemed inappropriate given physicians’ time pressures and training—this added a significant burden to women physicians at the detriment of the physician-patient therapeutic relationship and physician well-being.
Inequity in Patient Care in Ambulatory Resident Clinics
Resident continuity clinic is a key part of internal medicine training and an integral healthcare access point for many patients with vulnerable needs. Amat, et al, retrospectively compared characteristics and outcomes of resident and faculty patient panels in a large urban, academic, hospital-based primary care clinic.5
Their analysis found that faculty panels had significantly better population health metrics for chronic disease management and cancer screenings when compared to resident panels. While both resident and faculty patients had similar burdens of chronic and acute illness, resident patients were significantly more likely to have greater economic vulnerability, higher burden of psychiatric illness, increased high-risk behaviors, lower health literacy, and less engagement with the healthcare system overall. Resident patients were more likely to be “lost” to follow-up upon provider graduation with 53% of
patients not successfully transitioning to their new provider.
This study suggests that disparities in resident and faculty panel metrics are driven by factors such as socioeconomic vulnerability and continuity of care. This is an issue of health equity and emphasizes the importance of designing systems (both educational and clinical) that better support vulnerable patients in the academic setting.
The studies we have highlighted help to clarify the current landscape of inequities in various domains in academic medicine, including selection of medical trainees, promotion of academic careers, and in patient care in residency training. These works provide important context and act as a necessary step toward exploration of solutions to the vast inequities that persist across these realms. Creating positive change will require thorough and thoughtful interventions on multiple levels, from individual to systemwide. In part two of this series, we will share recently published interventions aimed at improving structural inequities as well as impactful innovations aimed at improving trainee education and promoting trainee wellness.