Changes in Sex, Race, and Ethnic Origin of Emergency Medicine Resident Physicians From 2007 to 2017.

Abstract

Diversity among residents in particular and, among the emergency medicine (EM) workforce in general, is a goal of both specialty societies and accrediting agencies.1, 2 The proportion of medical students and residents who self-identify as female has increased over the past few decades, but the proportion who are racial and ethnic minorities remains low.3-6 The percentage of emergency physicians and EM residents who are women and minorities are known to be lower than that of the general population.6, 7 To our knowledge no one has examined trends in representation of sex, race, and ethnicity among EM residents.7 Understanding longitudinal trends in representation of women and underrepresented minorities in EM is a crucial first step both for designing programs that increase diversity within graduate medical education (GME) and for improving retention and promotion of underrepresented attendings. This knowledge can both provide a benchmark and highlight areas for future inquiry. We obtained and reviewed publicly available, comprehensive, demographic information on resident physicians in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs from 10 administrations of the National GME Census.6, 8 The National GME Census is part of GME Track, a widely accepted resident database and tracking system introduced in 2000 that is a collaboration between the American Medical Association (AMA) and Association of American Medical Colleges (AAMC). The database is annually updated by all directors of programs accredited by the ACGME; directors confirm, edit, or add self-reported trainee demographic information. The database includes demographic data on resident sex, race, and ethnic origin as well as birthday, citizenship, and country of birth.6, 8 The study population of interest included all residents in ACGME-accredited programs over a 10-year period (academic years 2007–2008 to 2016–2017). The total number of resident physicians in that period ranged from 106,012 (2007–2008) to 124,096 (2016–2017).6, 8 We preidentified our subpopulation of interest as emergency medicine (EM) residents over the same period; the total number of EM resident physicians ranged from 4,479 (2007–2008) to 6,377 (2016–2017), reflecting 4.2% (2007–2008) to 5.1% (2016–2017) of the overall resident population.6, 8 The demographics of interest for this study were sex (female), race (white, Asian, or black), and ethnicity (Hispanic). Due to extremely low percentages of all residents and EM residents who self-identified as Native Hawaiian, Pacific Islander, American Indian, or Alaskan Native (all comprising less than 0.75% of the overall resident population for the period analyzed) the decision was made to not examine trends in these groups. The study was deemed exempt by the institutional review board of Partner's Health Care, Boston, Massachusetts. We calculated proportions for sex, race, and ethnicity of all resident physicians and of EM resident physicians each year; 10 years of data were included. We then tested for trends over time in sex, race, and ethnicity proportions among both the overall group and the EM subgroup, using logistic regression. Specifically, using year as the predictor, we assessed demographic trends across the 10 years where odds ratios (ORs) and confidence intervals (CIs) provide the magnitude of the effect per successive year. In this context of multiple testing, we reduced the alpha to 1% and increased the confidence level to 99% to limit the overall Type I error to 5%. Finally, we used recent year values (2016–2017) for demographics for both all residents and EM residents and compared them against similarly formatted July 1, 2017, U.S. Census Bureau population estimates to explore how resident population diversity from these groups relates to that of the current U.S. population.6, 9 While race and ethnicity data for medical students are reported by the AAMC, the format of these data are not comparable to the data from the GME or the U.S. Census Bureau, and they were omitted from this analysis. To facilitate comparison of sex, race, and ethnicity between all resident physicians and EM resident physicians (2016–2017 data) and the U.S. population (2017 estimates), 99% CI around the most recent year proportions for residents were reported. SAS version 9.4 (www.sas.com) was used. From 2007–2008 to 2016–2017 there has been a significant increase in the proportion of all resident physicians who are female (44.39% to 45.66%, OR = 1.004, CI = 1.002–1.006, p < 0.0001) but a significant decrease in the proportion of EM residents who are female (38.62% to 35.09%, OR = 0.979, CI = 0.971–0.987, p < 0.0001). The proportion female among EM residents was significantly less than the proportion female among non-EM residents (35.1% vs. 46.24%, p < 0.0001). Both proportions are less than that of the U.S. population estimates (50.8%; Table 1). There has been a significant increase in the proportion of EM residents who self-report as Hispanic (from 5.49% in 2007–2008 to 7.64% in 2016–2017, OR = 1.033, CI = 1.017–1.050, p < 0.001) but no significant change in the proportion of all resident physicians who identify as Hispanic. There have been no significant changes in the proportion of all residents or EM residents who identify as black. The current proportion of both all residents and EM residents who self-report as black or Hispanic is lower than that of the U.S. population estimates (black 13.4% and Hispanic 18.1%). There were significant increases in the proportions of all residents (26.1% to 26.85%, OR = 1.003, CI = 1.001–1.004, p < 0.001) and EM residents (13.4% to 14.215%, OR = 1.010 CI = 0.999–1.022, p = 0.02) who identify as Asian. The current proportion of all residents (26.85%, CI = 26.53%–27.17%) and EM residents (14.21%, CI = 13.13%–15.39%) who are Asian are both greater than that of the U.S. population estimates (5.8%). This analysis provides novel longitudinal data on the percentage of all ACGME-approved residents and EM residents who are female, Hispanic, black, and Asian, compared to the general population. During the 10-year period examined in this study the proportion of all female residents increased, but only slightly; the proportion of all female residents remains lower than that of the general population. The proportion of EM residents who were female, however, decreased over this same period. Reasons for decreasing proportions of females in EM residencies are likely multitudinous, but may include increased attractiveness of other specialties, perceptions of EM as having high-level organizational disparities, or other reasons that still need to be assessed.10, 11 Regardless, the fact that our specialty is losing women to other specialties should concern all of us, not just due to a commitment to equality, but also because gender diversity correlates with improved outcomes for both patients and for learners.10, 11 Blacks and Hispanics remain grossly underrepresented among all resident physicians and among EM resident physicians compared to that of the U.S. population despite extensive efforts from organizations like the AAMC and the National Academy of Medicine (NAM) and despite slight increases in the number of EM residents who self-identified as Hispanic.7, 12, 13 These findings demonstrate a discrepancy between the demographics of resident physicians compared to the population they serve; they possibly reflect disparities in undergraduate medical education as well. Novel efforts by medical schools and select EM residencies that identify and remove institutional structures propagating racial and ethnic disparities that hinder the pipeline of underrepresented minorities may improve these rates going forward.11-13 There are limitations to the study. First, this work is observational and provides trends in resident diversity; we cannot determine causality for the observed trends and are unable to assess the potential impact of diversity initiatives. Second, this work also focuses on EM residents; trends in EM may not be reflective of those in other specialties. Third, the demographic information in both data sets is self-reported. In conclusion, EM residencies' diversity, relative to both the U.S. population at large and to residents overall, has stagnated for racial and ethnic minorities and has worsened for women. A paradigm shift is likely required if there is to be true change. Renewed efforts are needed to address issues facing underrepresented groups in entering and persisting in EM careers.