Introduction

In part two of our Update in Medical Education series, initially presented during the 2022 Society of General Internal Medicine (SGIM) Annual Meeting, we highlight studies that offer targeted solutions to address racism, lack of diversity, and bias in medical school admissions and trainee evaluations. Additionally, we share innovative approaches to delivering educational content and improving trainee wellness.

Methods

Study authors employed a modified Delphi methodology to achieve group consensus on the selection of publications from journals that regularly publish medical education research. Additional details about methods used can be found in Part One of this two-part series.¹

Addressing Structural Inequities

This section highlights interventions aimed at addressing the lack of representation of minoritized populations in medicine and describe the efficacy of these approaches in achieving the desired outcome.

Improving Diversity in Medical Student Recruitment

Robinett, et al, report on the implementation of several interventions to reduce bias in the medical school admission process at one academic institution.² Interventions included: 1) providing unconscious bias training, 2) increasing recruitment efforts at colleges and conferences for underrepresented identities, 3) screening applications holistically and viewing the MCAT qualitatively, 4) blinding interviewers to GPA and MCAT scores, 5) soliciting applicant feedback about interview experience, and 6) diversifying admission committee membership. This multifaceted intervention significantly increased the number of applicants under-represented in medicine (URiM) who were interviewed, accepted, and matriculated. The proportion of UriM identifying students increased from 10-13% in the preceding three years to 24% in the matriculating class. Of note, there was no meaningful difference in average MCAT and GPA in the matriculating students when compared to prior classes. When interventions are made at each touch point in the recruitment process, measurable improvements in medical school diversity result.

Mitigating Bias in Letters of Recommendation

Zhang, et al, examined Program Director (PD) Letters of Recommendation (LORs) for the 2019 and 2020 applicants to one cardiology fellowship to explore the potential for bias mitigation following changes in the 2017 Alliance for Academic Internal Medicine (AAIM) LOR guidelines.³

Qualitative content analysis was conducted on 56 LORs, according to AAIM guideline adherence and applicant qualifying as under-represented in cardiology (URC; self-identified Black, Latinx, or female). Bias against URC applicants was observed in both letter types, with URC applicants described with communal language (i.e., descriptions of kindness and empathy) and non-URC applicants described with agentic language (i.e., descriptions of leadership skills). AAIM guideline-adherent LORs included less communal language in describing URC applicants. Compared with non-URC applicants, LORs for URC applicants utilized more doubt-raising language, including hedging, faint praise, and negative language, and characterized applicants as being earlier in career trajectory. Authors provided 14 high-yield, succinct recommendations for reducing bias in PD LORs, including following AAIM guidelines, anti-bias training, and third-party review of LORs.

Decreasing Bias in Training Programs

In 2018, the ACGME updated their Institutional Requirements, stating that programs must “engage in practices that focus on ongoing, mission-driven, systematic recruitment and retention of a diverse and inclusive workforce” in response to calls to recognize and address inequity in residency training.

Martinez-Strengel, et al, explored leaders’ perspectives on the ACGME diversity standards through structured interviews of twenty residency PDs and APDs.⁴ A constant comparative method analysis was utilized to identify the following key themes: unawareness of the new standard, misgivings about the standard, and cautious optimism that the standard could catalyze change. The authors highlight the difficulties identified by program leaders who lack the resources to change systemic inequities and call on academic institutions to empower their leaders with the support and direction required to instigate meaningful change.

Novel Approaches Promoting Learning and Wellness in Residency Training

This section highlights novel, creative approaches to improving the residency training experience.

Increasing Learner Engagement Through Bite-sized Teaching (BST)

Noon conferences often cover topics of high complexity in a high intrinsic load setting. In response to this structural issue, faculty at Emory University developed an educational model which they named Bite-Sized Teaching (BST) in which residents deliver a key concept, its main teaching points, and a schema to retain in a structured and concise 8-minute talk aimed at improving long-term retention.⁵

The team conducted a controlled trial: at one teaching hospital, all learners participated in a BST session on transfusion medicine while other learners received the traditional didactic session. The BST group scored significantly higher on a validated knowledge assessment immediately post-session. Although this effect size attenuated with time, their average scores continued to trend above those who received the traditional lecture. A survey of residents regarding their experiences with BST found that nearly 80% of respondents reported it was the “best” or “one of the best” formats for noon conference. They noted appreciation for the distilled nature of content, the delivery of multiple BST talks in one educational conference, and benefits of peer teaching.

Improving Trainee Well-being Involving the Show Scrubs

Holtzclaw, et al, developed a wellness curriculum for internal medicine residents at a single training program using episodes of the television program Scrubs.⁶ Twenty-four participants attended monthly, one-hour, faculty-guided discussion groups based on Scrubs episodes highlighting a theme relevant to trainees (i.e., patient mortality, physician cynicism, work-life balance). Available at $0.99 an episode, Scrubs was chosen as an inexpensive yet creative approach to acknowledge the harsh realities faced by trainees in the context of a comedy show. Faculty facilitated discussions using provided session objectives and open-ended questions.

Residents’ burnout scores on the abbreviated Maslow Burnout Index improved over the six months of the program. A focus group of participants revealed that residents found the informal nature of sessions and cross-PGY-year discussion to be helpful aspects of the curriculum. Residents universally voted to continue with this modality moving forward.

Conclusion

Medical education is undoubtedly changing. In the past year, many important innovations sought to address equity in the physician workforce, measured the effectiveness of societal guidelines on diversifying efforts, and demonstrated curricular innovations to reduce cognitive load and improve resiliency. We highlighted the promise of systemic changes to improving equity in medical school admissions, which emphasizes the impact of intentional, systemic approaches that aim to build a physician workforce that is representative of the population it serves. We recognized the value of national medical education societies’ efforts to put out guidelines to reduce bias in LORs and improve diversity in medicine, while acknowledging that these guidelines have yet to achieve the intended goal due to lack of awareness and limited adoption. We shared novel curricular approaches aimed at improving the resident training experience by innovating noon conference and creating reflective spaces.

In this upcoming year, we welcome additional studies to further identify and support the needs of our trainees, especially for learners with identities historically excluded from medicine. Systemic solutions to reduce the structural barriers, bias, and racism are needed to create environments where trainees can thrive and learn.