Using community data to inform medical school admissions: a cohort study of medical students in Ottawa, Canada

Achieving Diversity in Academic Internal Medicine: Recommendations for Leaders

Lack of racial diversity remains a persistent problem in medicine, most notably in the field of orthopaedic surgery. In 1999, an analysis by England and Pierce of orthopaedic residents who had been selected for residency programs from 1983 to 1995 found that the percentage of Blacks, Hispanics, and Native Americans had changed minimally over that 12-year period1. During that time, the rate of Black orthopaedic residents in training never surpassed 3.5%. In the >2 decades that have followed, there has been a continued call to increase recruitment of underrepresented minorities (URMs), particularly Blacks, into orthopaedic surgery2-6. Despite these directed efforts, orthopaedic surgery remains the least racially and ethnically diverse field among both surgical and nonsurgical specialties7,8. Lack of racial diversity correlates with substantial disparities in the culturally competent care of minority patients, with well-documented negative implications9-11. Improving diversity within our specialty is essential to achieving equitable postoperative and functional outcomes in our diverse patient population. While barriers to improving gender diversity have been and should continue to be explored, the profession of orthopaedic surgery must critically evaluate the barriers to recruiting URM applicants, particularly Black applicants. This is essential to help usher in the next decade with a racially diverse, inclusive, and equitable workforce. This article serves as the first in a series exploring the barriers to achieving a diverse, inclusive, and equitable environment for Black orthopaedic surgeons. The focus of the article is to examine the barriers to successful recruitment of Black applicants and provide tangible recommendations for improving racial diversity in residency. What Obstacles Do Black Candidates Face in Matching into Orthopaedic Surgery? The barriers to Black students' pursuit of orthopaedic surgery as a career are both intrinsic and extrinsic. Intrinsically, Black students assess the career choices that are available to them by evaluating what those in their own communities are doing or are expected to do. In a 2013 article, Hill and Vaughan explored the concept of "paradigmatic trajectories" to explain ways that students self-select out of pursuing surgical specialties12. Black medical students are frequently unable to see, identify, or interact with orthopaedic surgeons who look like them. These students are repeatedly informed about the difficulty of getting into orthopaedics and are denied "experiences of participation," which leads them to being unable to see themselves as orthopaedic surgeons. By contrast, their majority peers often have the opposite experience: they see many available role models in orthopaedics who match their demographic, serve as role models, and provide hands-on experiences. As this scenario is repeated each academic year, the disparity between the number of White and Black medical students choosing to pursue orthopaedics as a specialty increases, a process that, to date, appears perpetual. Extrinsically, the pipeline of minority students to orthopaedic residency positions is filled with detours due to the redirection of minority students to other career pathways. This discouragement begins early for Black students, particularly Black male students, especially in educational environments in which their teachers are White. A study using survey data from the Education Longitudinal Study of 2002, which was conducted by the U.S. Department of Education's National Center for Education Statistics, evaluated how teacher expectations influenced student performance among 6,000 high school students13. It found that there were clear racial disparities in teacher expectations of student performance. For example, the study found that teachers expected 58% of White high school students to obtain a 4-year college degree, but expected only 37% of Black students to do so. Furthermore, when considering these same Black students, White teachers were significantly less likely than their Black colleagues to expect the students to achieve a 4-year college degree. This difference was even more pronounced when the student was a Black male. Ultimately, the study concluded that negative expectation bias contributed to a self-fulfilling prophecy: only 29% of Black students in the study obtained a 4-year degree. Certainly, diminished expectations of Black students may carry similar consequences in higher education. For Black medical students, the lack of early exposure to orthopaedic surgery and the elimination of student-generated stereotypes regarding their potential fit for the specialty are critical roadblocks to increasing applications to residency programs. Schmidt et al. noted that the timing of exposure and student-perceived stereotypes, among other factors, were major determinants in a medical student's decision to pursue surgery14. An early introduction to the field of surgery was particularly important in increasing a student's interest in a surgical career. For those Black students who persevere in choosing orthopaedics, being chosen for an orthopaedic residency program is still problematic. The benchmarks that are used for resident selection are arbitrary at best, and biased and discriminatory at worst. In the 2018 National Resident Matching Program (NRMP) survey of program directors15, 91% of orthopaedic residency program directors cited the United States Medical Licensing Examination (USMLE) Step-1 score as the most important factor for selecting students to interview. Membership in the Alpha Omega Alpha (AΩA) honor society was the third most important factor listed, and the Medical Student Performance Evaluation (MSPE) was noted as the seventh factor. Ramkumar et al. confirmed that orthopaedic surgery interview offers for applicants correlated most with AΩA status, the Step-2 Clinical Knowledge score, and the Step-1 score16. This has important implications for URM students. Wijesekera et al. reported that the USMLE perpetuates downstream pipeline disparities stemming from parental education or socioeconomic status, especially for URM students17. Clinical clerkship evaluations and the MSPE have demonstrated a negative bias toward Black students compared with their White counterparts18, and there are implicit differences in the words that are used to describe different ethnic groups19. Boatright et al. reported that Black students were less likely than an equivalent White student to be selected for the AΩA honor society, even after controlling for Step-1 scores, research, leadership roles, and membership in the Gold Humanism Honor Society20. The data reveal that there is inherent bias in the objective measures that are used by orthopaedic surgery programs to vet their applicants. Although the current measures select excellent future orthopaedic surgeons, these measures ultimately favor a specific group, which is defined by Rubright et al. as "a native English-speaking White male U.S. citizen at average age"21 at the expense of applicants who do not fit this mold. What Current Strategies Have Been Implemented to Increase the Number of Black Medical Students Applying into Orthopaedic Surgery? In 2020, racial inequality, health disparities, and social injustice have played a central role in the civil discourse within and outside of the field of medicine. The lack of racial and ethnic diversity in orthopaedic surgery deprives the specialty of the diversity of ideas and lived experiences that can speak to social issues that affect our diverse patient population. Different national organizations have attempted to champion diversity efforts in orthopaedics. The American Academy of Orthopaedic Surgeons (AAOS) has incorporated diversity initiatives into its strategic goals. These goals include understanding and responding to the diversity of the patient population, enhancing the delivery of culturally competent care, and supporting efforts to diversify the profession and the orthopaedic workforce. Despite these efforts, orthopaedic surgery still critically lags behind other subspecialties with regard to increasing the diversity of its surgeon workforce, which speaks to a critical need to further prioritize diversity in orthopaedics through a coordinated multidisciplinary approach. At the 2011 AAOS/ORS (Orthopaedic Research Society)/ABJS (Association of Bone and Joint Surgeons) Musculoskeletal Healthcare Disparities Research Symposium, Dy and Nelson proposed that cross-cultural communication and workplace diversity should be valued by all orthopaedic surgeons and should be championed by the leaders of academic orthopaedic departments2. They suggested that structured collaborative initiatives should be implemented by departmental leadership at each medical school in coordination with female and URM orthopaedic surgeon role models. Furthermore, they recommended that national orthopaedic societies like the AAOS should work in concert with diversity-minded orthopaedic associations such as the Ruth Jackson Orthopaedic Society, the J. Robert Gladden Orthopaedic Society (JRGOS), and the American Association of Latino Orthopaedic Surgeons to recruit and prioritize the mentorship of underrepresented populations into the field of orthopaedic surgery. In tandem with the efforts of the AAOS, mentoring pipeline programs such as Nth Dimensions coach applicants on how to prepare and position themselves as highly qualified applicants into the field of orthopaedic surgery. Nth Dimensions has developed a longitudinal pipeline curriculum that is designed to engage medical students in their first year of medical school. The program has multiple phases that maintain contact after exposure, including webinars, symposia, and an immersive summer internship program, as well as longitudinal mentorship and professional development. The program intentionally exposes students to multiple hands-on experiences through bioskills workshops and physician-shadowing. In addition, Black students are exposed to an extensive network of Black orthopaedic surgeons with a wide variety of lived experiences. From the initial contact through residency completion, the Nth Dimensions "community" reinforces orthopaedics as a viable career. This exposure was found to significantly increase the odds of URM participants applying to orthopaedic residencies by 15-fold22,23. To our knowledge, no other pipeline programs that focus on improving racial diversity within medicine exist with data to support their success. For Programs That Historically Lack Ethnic Diversity, How Can Residency Program Leadership Increase Recruitment of Black Orthopaedic Residents? A study by Adelani et al. recently reported that the number of orthopaedic training programs with no Black residents actually increased from 40 programs in 2002 to 60 programs in 2016, with the worst year being 2011, when 76 programs had no Black residents24. Recently, McDonald et al. surveyed program directors and coordinators on perceived barriers to increasing the diversity of their individual orthopaedic programs25. Nearly 70% of respondents said that the lack of enough URM faculty hindered their ability to recruit URM applicants. Fifty-six percent of programs responded that they consistently ranked URM applicants to match, but these applicants matched elsewhere. Fifty-five percent of programs felt that their programs could be more diverse, but the programs simply did not receive enough applications from URMs. Interestingly, 32% of programs were not specifically trying to recruit URM applicants at all. While pipeline programs such as Nth Dimensions provide a solid foundation for improving the number of Black students pursuing orthopaedics, future strategies need to implement program-level initiatives to further these goals. Orthopaedic residency programs that are affiliated with medical schools should nurture an early interest in orthopaedic surgery and musculoskeletal care among Black and other URM applicants through endorsement of a musculoskeletal education curriculum for medical students. Early exposure to orthopaedic surgery fosters more interest in the field, particularly among minorities and women22,23. Bernstein et al. reported that medical schools that required instruction in musculoskeletal medicine had significantly higher rates of application to orthopaedic residency programs26. This difference was even more pronounced among female and URM medical students. On a broader scale, increasing the diversity of orthopaedic faculty has downstream implications in the growth of diversity in residency programs. Okike et al. reported that URM medical students who attended medical school at institutions with high URM representation among orthopaedic faculty (>8.8%) or orthopaedic residents (>10.5%) were more likely to apply into orthopaedics than those with low URM representation among orthopaedic faculty (<4.0%) and orthopaedic residents (<6.1%)27. We would also submit that simply hiring Black faculty is not sufficient to move the needle toward a more diverse workforce. To improve racial equity and inclusion, there needs to be a concerted effort to support and advocate for Black faculty in leadership roles within orthopaedic departments and on a national level. We also suggest that orthopaedic department leadership become actively involved in diversity-related orthopaedic organizations such as the JRGOS and Nth Dimensions. This offers opportunities to interact with the majority of Black residents, fellows, and faculty within the orthopaedic specialty nationwide, and goes a long way toward improving a culture of inclusion within the field. Nearly every medical school in the U.S. has local chapters of medical student URM groups such as the Student National Medical Association (SNMA) and the Latino Medical Student Association (LMSA). Sponsorship of an SNMA or LMSA meeting by the affiliated orthopaedic department provides a rich opportunity to interact with Black and other URM students and provides exposure to the orthopaedic specialty. This also allows faculty to interact with more Black students, developing critical mentorship and sponsorship opportunities for these students that not only foster a more inclusive environment within that orthopaedic program but develop critical pipelines for future Black faculty recruitment and development. In "Ten Key Steps for Chairs, Program Directors, and Faculty to Serve as Allies During This Racial Crisis," Ross et al. highlighted the importance of developing transparent nationwide metrics on racial diversity in orthopaedics28. This concept mirrors that of the value-based care philosophy that links financial incentives to surgeon performance on a set of defined measures29. The JRGOS has the most comprehensive database of Black orthopaedic surgeons in the U.S. Based on their data, a diversity ranking was created for the 2020-2021 academic year30. Of the 56 orthopaedic residency programs that had Black residents this academic year, the following programs were ranked in the top 5 in terms of the highest percentage of Black residents: Howard University (70%), Tulane University (27%), Kingsbrook Jewish Medical Center (20%), New York University (15%), and Stanford University (14%). One argument against ranking metrics such as these is that they could potentially foster competition between programs for a small finite population of qualified Black applicants. However, the counterargument to this would be that the applicant pool is not truly finite. Poon et al. evaluated orthopaedic applicants between 2005 and 2014 and found that 5.7% were Black applicants and 71% were White applicants8. However, during that same period, only 3.8% of orthopaedic matriculants were Black while 74.7% of orthopaedic matriculants were White (an acceptance rate of 46% versus 73%). As established diversity pipeline initiatives increase the number of Black and other URM applicants into orthopaedic surgery, there needs to be an increase in the acceptance and retention of these students among a broader group of residencies. Recruitment of Black and other URM applicants must be an active and sustained effort. Diversity metrics such as the JRGOS rankings allow residencies that lack diversity to objectively compare themselves with more diverse programs on a granular level. However, we would further argue that program-level information on underrepresented populations in orthopaedics should be readily available through national orthopaedic associations such as the AAOS or the American Orthopaedic Association (AOA). Furthermore, programs should perform an objective and critical analysis of negative factors that have impeded the recruitment and retention of Black residents and faculty at their programs. These factors could contribute to the outward perception of a noninclusive, even hostile, environment, which could deter Black applicants from considering a program. Exploring the root causes that impede diversity may not achieve immediate gains in recruitment, but may help prepare a program for future Black applicants. These applicants will eventually recognize concerted efforts by a program for achieving inclusive culture, and they may choose to attend a program that may not historically have been diverse. The successful recruitment of Black applicants into the field of orthopaedic surgery also requires that the resident selection process eliminate unconscious biases in the screening of potential applicants. One means of achieving a diverse selection pool is to modify the screening criteria of potential applicants. Blind screening of potential candidates has been proposed as a way to mitigate racial, ethnic, gender, and medical school bias in the screening process28,31. Fadem et al. found a significant correlation between the income level of a medical student's parents and that student's Medical College Admission Test (MCAT) and USMLE scores for both minorities and nonminorities32. A study evaluating general surgery applicants found that discrete USMLE cutoffs eliminated URM applicants at a higher rate than non-URM applicants33. The concept of "distance traveled" is another screening process that is used in the technology and corporate sectors as a means of mitigating unconscious bias in hiring practices, which have favored more privileged and homogeneous applicants34,35. The "distance-traveled" concept factors in where a job candidate came from and how many obstacles he or she had to overcome to get to where he or she is currently. Recently, medical schools have used "distance-traveled" metrics to admit a more racially/ethnically, culturally, and financially diverse group of medical students while deemphasizing reliance on standardized test scores in screening practices36,37. As the USMLE Step-1 shifts to a pass/fail format from the numerical score format that has been perceived as disadvantageous to minority students38, use of a "distance-traveled" screening measure may allow for the prioritization of candidates from diverse backgrounds who demonstrate higher levels of resilience and "grit," which are considered desirable traits among successful orthopaedic residents39,40. Furthermore, we recommend that all selection committee members at residency programs should complete bias/allyship training prior to the selection process. In a study by Capers et al., investigators evaluated the value of identifying bias in medical school admissions41. All 140 members of the Ohio State University College of Medicine (OSUCOM) admissions committee were administered the Black-White Implicit Association Test (IAT) prior to the 2012-2013 application cycle. All of the groups surveyed, particularly male members and medical school faculty, demonstrated a significant White male preference. The IAT results were released to the participants, with 48% admitting that they were conscious of their individual results when interviewing candidates during the next application cycle. This information resulted in measurable change: the class that matriculated following the IAT exercise was the most diverse in OSUCOM's history at that time. The implementation of comparable bias training programs within orthopaedic residencies may achieve a similar effect. Summary Orthopaedic surgery has the lowest percentage of Black representation of any specialty, and there has been minimal to no improvement on this front over the last 2 decades. As racial and ethnic inequities in America are increasingly highlighted, it is clear that orthopaedic surgery as a field has fallen short regarding diversity. Orthopaedic surgery can improve its racial diversity with concerted effort and the active engagement of future applicants of color. We recommend active recruitment of Black applicants with the utilization of established pipeline programs and organizational resources. Furthermore, strategies to increase the number of Black applicants to orthopaedic residency programs require paradigm shifts in medical students' perception of orthopaedics as a viable career path and strategic preparation of residency program environments for URM-resident recruitment. Most importantly, programs must take a proactive role in creating a safe and fair working environment for their URM residents. Our hope is that these strategic collaborations can contribute to measurable change in racial diversity in orthopaedics over the next decade.

University of Missouri School of Medicine in Columbia

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ABSTRACTPhenomenon: This study explored Black/African American and Hispanic/Latino medical students' perceptions of the medical school admissions process. Previous research has explored other elements of the medical education continuum. However, little is known regarding minorities' perceptions of navigating the medical school admissions process. To address this gap in the literature, this exploratory study suggests a conceptual model describing why minorities apply to medical school and the influences affecting their admissions experience. Approach: This qualitative study utilized a grounded theory approach. Between December 2012 and January 2014, the principal researcher conducted one-on-one telephone and in-person small-group interviews, as well as web-based telephone feedback sessions, with Black/African American and Hispanic/Latino medical students. Findings: Thirty-three students participated, including 23 Black/African American and 10 Hispanic/Latino medical students. Participants represented 25 U.S. allopathic medical schools. Emergent themes are categorized under 2 headings: (a) motivations for a career in medicine and (b) barriers and supports. Motivations for a career in medicine include perceived fit, prior experience or knowledge, encouragement and role models, desire to help others, interest in science, and perceived benefits. Barriers and supports included information, guidance and social support, financial and academic factors, and persistence. Insights: Building on theories of student college choice and academic capital formation, the researcher's analysis and interpretations result in the proposal of a conceptual model describing minority applicants' experience in medical school admissions. The study also suggests research and practice implications related to premedical advising, mentoring, financial assistance, information, outreach, and data collection.

Overview of the Geriatrics Curriculum Medical Students’ Training The University of Missouri (MU)–Columbia School of Medicine is located in a state with one of the largest concentrations of rural elderly residents. The recently organized Center of Excellence on Aging at MU brings together resources from the Schools of Medicine, Nursing, and Health Professions. The curriculum at the University of Missouri is recognized for its successful problem-based learning (PBL) approach to teaching medical students. During the first two years, students learn through small-group discussions of clinical cases, thus integrating the basic sciences and clinical reasoning. This basic science/PBL component of the curriculum offers an ideal opportunity to include basic science foundations and the clinical aspects of geriatrics medicine. The introduction to patient care (IPC) is the other curricular component in the first two years. IPC is the foundation for clinical training. Students learn the fundamentals of history taking and physical examination, psychosocial aspects of medicine, clinical epidemiology, and selecting and interpreting diagnostic tests. This is also an ideal time to include the unique aspects of history taking and physical examination of elderly patients. Also included are the psychosocial aspects of aging, end-of-life issues, and death and dying. The AAMC/Hartford initiative has allowed us to initiate several very successful preclinical and clinical activities for our students. During the course of our grant, we created six additional PBL cases. The Senior Teacher Education Partnership (STEP) is an innovative program linking first-year medical students with elderly patients in the community. Students and STEP partners attend group educational sessions led by program faculty and arrange, on their own, social activities, physician office visits, and even exercise dates. This program received the Catalyst Institute's national award for excellence and innovation in 2002 and was recently recognized as a model program for education in geriatric medicine (Adams D. Gray days ahead. Am Med News. Feb 10, 2003:10, 11). Using the first cohort of STEP and interested students from the existing family medicine and internal medicine interest groups, we have started a geriatrics interest group. During the required third-year clerkship in family medicine, students participate in two cases to explore issues of geriatric polypharmacy, falls, depression, dementia, multidisciplinary management, and health-care financing. Also during the clerkship, some students work with geriatricians in an ambulatory setting. During the AAMC/Hartford project, we implemented the acute care for the elderly (ACE) curriculum for third-year students on the internal medicine clerkship. Students complete an online module on geriatric assessment and then apply three instruments to an elder for whom they are caring on the inpatient service. Students on each of the other required rotations encounter older patients, but the explicit curricular elements are few. In 2001, we tested a pilot program of one full day of EPEC (Education for Physicians on End-of-Life Care) with 11 fourth-year medical students. This spring, we conducted mandatory EPEC training for the entire third-year class. Among the rural experiences available to our students is the rural training track, which includes 12 to 15 students in each third-year class who have special interests in rural health care. This program was first organized in partnership with our federally funded Area Health Education Center (AHEC) and now operates with state support. For six months in the third year, students complete required rotations in rural communities and retain a continuity primary-care practice. Since up to half of the visits in these practices may be from elderly people, this experience enables students to care for patients across settings of care and specialty services, much like a real primary-care physician in office practice. Residency Program We have built a modest program in geriatrics medicine for the family-practice residency program. There is a monthly presentation, during the residents’ didactic afternoon, on a core geriatrics topic, such as falls, delirium, or depression in older adults. A required month-long rotation includes experiences in the multidisciplinary geriatrics clinic, adult day care, home care, and nursing home care. Each resident also has a two-year longitudinal experience in a community nursing home under the supervision of attending physicians and nurse practitioners. The residency program has two rural family-practice centers, and residents participate in home and nursing home care in rural communities. Regarding end-of-life care, we use parts of the EPEC curriculum and a short community-based hospice experience. Our residents in internal medicine have a one-month rotation at the adjacent Department of Veterans Affairs (VA) hospital, where they spend time in the geriatrics clinic, on the GEM (geriatric evaluation and management) and nursing home units, and with the home-based primary-care team. Fellowship Training We developed a geriatrics medicine fellowship program in 1993 to educate academic geriatricians with special interests in the needs of rural communities. Three of our fellowship graduates have joined our own faculty, and one is on the faculty of the University of Virginia. The geriatrics medicine fellowship is a part of the academic family medicine fellowship that began in 1979. All fellows take coursework in epidemiology, research design, biostatistics, and the health-care system. Fellows who complete the two-year curriculum receive a master of science degree. We have weekly seminars in geriatrics medicine that include core clinical topics, a geriatrics journal club, and monthly end-of-life care conferences. Finally, we host a monthly campus-wide team for interdisciplinary research seminar, which is open to students, residents, and faculty members. Continuing Education and External Relationships MU has an accredited Office of Continuing Education and Extension for the Health Professions, which has attracted more than 4,000 primary-care physician registrants to its programs during the last five years. In 1990, funded by a health of the public grant from the Pew Charitable Trusts and the Rockefeller Foundation, our geriatricians created an alliance with a group of rural primary-care physicians providing care for the frail elderly. Among the enduring products of this relationship was the Physicians Advisory Committee to the Division of Aging (State of Missouri), an annual conference, the Long-Term Links newsletter, and the founding of the Missouri Association of Long-Term Care Physicians (MALTCP). Each year, at the Caring for the Frail Elderly conference, a multidisciplinary group of 150 to 200 health-care professionals gathers for a two-day meeting to address long-term care practice. Long-Term Links has a requested circulation of over 600 long-term care physicians, nurses, and administrators from across Missouri. MALTCP is a multidisciplinary group of professionals from around the state who are committed to improving the quality of care in nursing homes. Curriculum Management and Governance Structure The medical student curriculum is a partnership between the curriculum board and the dean's office. The curriculum board is a nine-member group of elected faculty members who oversee the medical student curriculum. Students representing each medical student class are ex-officio members. The board oversees the development and maintenance of a comprehensive list of outcome goals or competencies for graduates of the School of Medicine (SOM); establishes explicit learning objectives consistent with the goals to be used to define the appropriate content of courses and to design the evaluation process; makes recommendations about curriculum content, methods of instruction, and evaluation to faculty members who plan individual blocks and courses; provides an annual report to the dean and the faculty; serves as an advocacy group for the faculty members in their roles as teachers; promotes faculty development; and approves the academic calendar. Within the dean's office, the Office of Medical Education (OME) oversees the curriculum (see Figure 1). Under the leadership of the senior associate dean for education and faculty development, OME consists of the associate dean for curriculum, associate dean for student programs, assistant dean for graduate medical education, the director of evaluation, the financial aid officer, and the admissions coordinator.FIGURE 1. Office of Medical Education Organizational ChartThe geriatrics curriculum was incorporated with full OME support. Dr. Michael Hosokawa, associate dean for curriculum, was co-principal investigator (PI) on the Hartford/AAMC project. This summer, the University of Missouri–Columbia School of Medicine was selected by the Donald W. Reynolds Foundation to receive a four-year, $1.9 million geriatrics training grant. This funding is enabling us to build upon and enhance the geriatrics education efforts begun with the Hartford/AAMC grant and is further evidence of OME's commitment to geriatrics education. The geriatrics education programs are multidisciplinary, cut across departments, and have the full support of the dean's office. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change In 1993, the SOM implemented the PBL approach, which provides opportunities for integrating a broad range of topics into the case discussions and for incorporating the basic concepts of geriatrics medicine and gerontology. Over 60 cases are in use in the preclinical curriculum at any given time, and the number with a focus on geriatrics could be substantially increased. The flexibility of the PBL curriculum is a tremendous asset in introducing new concepts. Theme for the Geriatrics Program During the AAMC/Hartford grant, we reviewed the literature, performed a self-study, and had discussions with key geriatrics medicine faculty as well as subspecialist faculty physicians who care for older patients. During this time of self-assessment, we developed ten principles of geriatric care that will guide our educational initiatives. These concepts (see List 1) are meant to assist us as we share our vision with learners and colleagues at all levels.LIST 1. Ten Principles of Geriatrics Care Learning Outcomes for the Geriatrics Curriculum We have not developed formal learning outcomes, but we are developing informal ones in accordance with an institutional commitment entitled MU 2020. These outcomes include that each of our graduates is able to deliver effective patient-centered care, honest, with high ethical standards, knowledgeable in biomedical sciences, evidence-based practice, and societal and cultural issues, able to think critically and solve problems, able to communicate and collaborate with patients and other members of the health-care team, and committed to improving quality and safety and to lifelong learning and information mastery. Special Programs Senior mentor program We have formed a partnership with senior citizens in our community that promotes geriatrics in the first and second years of medical education and addresses the problem of stereotyping the geriatric population. The STEP program matches medical students with seniors for two years or more, providing the former with the opportunity to know healthy, active senior citizens and breaking down the stereotypes students may have (e.g., that most elderly patients are frail and in poor health). As a result of this program, students have reported changes in their understanding of patients’ experiences. Senior volunteers were recruited from a senior membership program associated with MU Health Care. The dean's office played a vital role in validating the STEP program, informing students about the program through OME's online newsletter, an e-mail campaign, the annual student activities fair, a poster on the M-1 bulletin board, and brochures. The outcomes of the program have surpassed expectations. The program's success has earned it a national award. Most important, our experience highlights the importance of exposure to healthy older people in implementing positive attitude changes among medical students. Based on student interviews, we believe STEP will make a difference in the way medical students will practice medicine. A gift from the family of Robert M. Heyssel, MD, provides support for this program and ensures its continuation. Community partnerships MU's School of Medicine has strong ties to partnerships that provide valuable educational experiences: A network of community-based primary-care teaching practices Affiliated nursing homes and assisted living facilities (attending over 200 patients) A multidisciplinary comprehensive geriatric assessment clinic An ACE model of care on the inpatient internal medicine and family medicine services An eldercare Center (adult day care) run by the School of Health Professions Senior Care, a community-based, care-coordination program (a home-health agency based in the School of Nursing) A source of relevant information on geriatric medicine through our successful continuing education programs and our links to professional organizations of physicians caring for the elderly Faculty development programs for the geriatrics curriculum Although our AAMC/Hartford project did not specifically address faculty development, we have a long history of providing continuing education in geriatrics through the Caring for the Frail Elderly conference and the Long-Term Links newsletter. Student interest groups With the Hartford/AAMC funding, the SOM established a geriatrics interest group (GIG). Palliative care and end-of-life courses In 2002, EPEC classes were offered to the M4 class. In 2003, mandatory EPEC training for all M3's took place on March 28. Resulting Pedagogical Changes There were six new PBL cases for the first two years of medical school (one new dementia case, two congestive heart failure cases, two stroke cases, and one Parkinson's case). The STEP program has been enormously successful in linking our students with seniors in the community. We are happy to report that STEP has become an integral M1 experience that will continue beyond the grant. The GIG was established, and we are happy to report that this group will continue and expand in years to come. We have incorporated geriatrics into the third-year curriculum, including the ACE program in internal medicine. This program is up and running and has become fully incorporated into the third-year curriculum. Application of Computer Technology The OME promotes openness to changes in technology. We see our students as information interpreters and focus on their integrative and evaluative skills. Computer technology plays a major role. We use Web-based instruction and integrate Web-based searching exercises into our PBL curriculum. This type of instructional tool is used in clerkships and other rotations. Of particular note is the ACE tool kit developed for use during the internal medicine clerkship. This tool kit uses Web-based instruction to teach students the value of geriatrics assessment; how to improve their communication skills with patients, families, and other caregivers; and how to appreciate fully the multidisciplinary team approach to patient care. Students’ Clinical Experiences in Geriatrics These experiences begin with the first year in the ambulatory-care experience. This is a shadowing experience for first-year students. When possible, students with an interest in geriatric care (such as those enrolled in the STEP program or the GIG group) are assigned to the faculty geriatricians for this experience. During the third year of the curriculum, the clerkships in family medicine and internal medicine are expanding the geriatrics training that the students receive. Family physicians with certificates of added qualifications in geriatrics are key members of this project. The clerkship director for internal medicine is also a key member of the project. She has developed a new segment of the internal medicine clerkship curriculum, and has also developed a tool kit (mentioned above) for students to use during their internal medicine clerkship. The Program’s Assessment and Evaluation Instruments In our OME, we use evaluation to determine whether each student is acquiring the appropriate knowledge, skills, values, attitudes, and behaviors to function as a competent physician. Evaluation also provides useful feedback to students about their progress. Results of formal evaluations are used by the faculty to judge the progress of students and are used by individual students for self-improvement. The first year of the medical school curriculum consists of four nine-week blocks. Each block has two components: basic science/problem-based learning (Bsci/PBL) and IPC (introduction to patient care). Each student receives a grade for both components. All examinations occur during the ninth week of each block. There are no midblock exams or quizzes. Evaluation of PBL group performance is a continuous process that takes place during the eight weeks of PBL small-group meetings. Evaluation tools and programs are being developed to support continuous improvement of the curriculum. Resources Required There is substantial support for geriatrics training at our school. For example, the PI receives dean's office support to lead geriatrics academic programs. In addition, federal grants from the Health Resources Services Administration (HRSA) are currently supporting family medicine residency efforts in geriatrics, and another grant helps to support research infrastructure development. Current HRSA grants provide partial support for the academic training of our geriatric medicine fellows. MU's continuing education activities, such as the Caring for the Frail Elderly conference and the Long-Term Links newsletter, have been self-supporting through fees for the conference and unrestricted educational grants that will help further proposal goals. Geriatrics research/education has just been named as one of four major endowment efforts by the dean of the School of Medicine, along with cardiovascular disease, cancer, and child health. A $10 million endowment is targeted for geriatrics. In recent months, a donor referred to OME has created an endowment to help support the STEP program. All of this reflects the institutional recognition of, and commitment to, advancing training programs in the care of the elderly. The senior associate dean for education and faculty development is proud of the progress we have made in the way we deliver and teach care of the elderly. She backs our efforts to continue development of a geriatrics program of the size and scope necessary to deal with Missouri's aging population. Requirements to Sustain the Program Continued OME support, along with a new grant award by the Reynolds Foundation, will allow us to continue to maintain and improve the work we have started. Unanticipated Outcomes Recognition and funding from the Reynolds Foundation The extraordinary success, recognition, and continued funding of our STEP program Interest at the dean's level to make geriatrics and its endowment priority efforts Impact of External Funding External funding is allowing us to extend and expand the innovations developed under the AAMC/Hartford grant through new PBL cases, expansion of the STEP program, enlarging the GIG group, enhancing IM acute care of elderly experience, and developing a home-care curriculum for third-year students. For further information, contact Steven C. Zweig, MD, MSPH, at 〈[email protected]〉.

Who Is Indoctrinating Whom?

ObjectivesThe aim of this study was to clarify and compare the socioeconomic backgrounds of medical students with those of other health professions and non-health faculty students in an era of...

Gender segregation by specialty during medical school.

By considering applicants’ humanitarian interests, medical schooladmission committees play a crucial role in helping medical schoolsfulfill their social contract with the public—the selection of com-petent and caring future physicians. Validly assessing such diversequalities, however, remains problematic. Admission committees useundergraduate grade-point average and Medical College AdmissionTest scores as markers of intelligence and aptitude. Applicants’ hu-manitarianism or altruism is less amenable to valid measurement.Usually, such characteristics are expressed through the applicant’sself-reported participation in community service activities. Becausedetails regarding these experiences are often sketchy, the scope anddepth of an applicant’s community service experience remain dif-ficult to ascertain and quantify. Admission committees rely on com-munity service experience information in selecting applicants whomay have altruistic inclinations. Little is known about the predic-tive capacity of this non-academic performance variable as it relatesto behavior in medical school, or future medical practice.This study addresses three questions related to the use of appli-cants’ community service experience for selection and predictionpurposes by an admission committee. First, using key medicalschool admission file materials, can reviewers reliably assess appli-cants’ experiences with, and orientation toward, community ser-vice? Second, do reviewers use specific aspects of community serviceto determine their overall assessments of community service in-volvement? Third, can these assessments predict students’ voluntaryparticipation in a new first-year service–learning elective?

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BackgroundDiversity and race-concordant relationships contribute to improved patient experiences and outcomes. In contrast, the representation of underrepresented in medicine (URiM) individuals in different medical specialties is declining. The essential pathway to improving diversity within the future workforce centers around the inclusion of a diverse cohort of medical students. We aimed to examine the diversity of medical school applications and admissions across sex, race and ethnicity over the past decade.MethodsThis study used data from the Association of American Medical Colleges from 2015 to 2024. URiM individuals refer to minority populations that are underrepresented in the medical profession, including Black, Hispanic, American Indian or Alaska Native (AIAN), and Native Hawaiian or Other Pacific Islander (NHPI). Diversity representation was measured using the representation index.ResultsThere was an increasing trend in medical school applicants among females but a decreasing trend among males. The number of Asian female applicants increased significantly (51.33%), while the numbers of Black (29.74%) and Hispanic (14.98%) female applicants also showed notable upward trends. Matriculation rates for Black females (mean: 33.64%; SD: 2.28%) and overall URiM females (mean: 35.94%; SD: 2.02%) have consistently remained below White females (mean: 44.22%; SD: 2.66%), Asian females (mean: 43.57%; SD: 2.59%), and the national average for females (mean: 40.96%; SD: 2.05%) over the past decade. The findings indicate that all racial and ethnic groups were underrepresented among both applicants and matriculants over the last decade, with the exception of Asian individuals. The representation index between matriculants and applicants among Black females (-1.46 vs. -1.19; P < 0.001) is widening, which may help explain the underrepresentation discrepancy for overall URiM females (-2.09 vs. -1.83; P < 0.001).ConclusionThis study highlights both progress and persistent challenges in achieving racial and ethnic diversity in U.S. medical education. While female and URiM applicant numbers have increased, matriculation disparities remain, especially among Black and URiM females. The widening representation gap between applicants and matriculants underscores structural barriers that continue to hinder equity in medical school admissions. A more inclusive physician workforce should begin with meaningful reform in how future doctors are recruited, supported, and selected.

The Australian Medical Council requires all accredited Australian medical schools to have specific admission and recruitment policies for Indigenous Australian students. However, there is no clear evidence about how these students can be retained through to graduation. This study aimed to explore the training experiences of Indigenous undergraduate medical students and their perceptions of the factors influencing their progression through training. Methods We used a qualitative methodology involving focus groups. All participants had successfully completed at least 1 year of the Bachelor of Medicine programme at the University of Newcastle, New South Wales, Australia. Sixteen of 18 eligible students participated in the study. The factors that influence an Indigenous student's progress through medical training are multi-faceted and inter-related and are associated with student support, course content and styles of learning, personal qualities (such as confidence and coping skills), discrimination and distinctive cultural issues pertinent to Indigenous students. Both academic and non-academic factors affect the progression through training of Indigenous medical students. A number of individual and systemic interventions which actively encourage a range of support networks, increase confidence and coping skills, and reduce cultural clash by assertively addressing discrimination and stereotyping need to be introduced. The outcomes of this work may provide some guidance to medical schools engaged in implementing strategies to enroll and support Indigenous students.

Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey. The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description. A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society. Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools.

University of South Carolina School of Medicine.