The Path to Diversity and Inclusion in Neurology: Virtual Residency Recruitment

In the US, a country where ethnic minorities continue to be burdened by disparities in health care access, disease incidence, and morbidity, an ethnically diverse group of physicians can facilitate equitable care for communities of color. ^1,2

Despite this, Black or African Americans, Hispanics, American Indians, Native Hawaiians, Native Alaskans, and Pacific Islanders only make up 11% of the US physician workforce and 10% of US neurologists.^2,3 This trend appears to arise much earlier in the physician pipeline, with less than 13.8% of neurology residents belonging to Underrepresented in Medicine (UiM) communities.⁴

Justin Jordan, MD, clinical director, Pappas Center for Neuro-Oncology, Massachusetts General Hospital, and his colleagues believe the virtual interview format is a potent tool for facilitating equity in residency programs.⁵

Virtual Residency Recruitment

In response to the COVID-19 pandemic, the Association of American Medical Colleges  (AAMC) issued virtual recruitment recommendations for residency programs in the 2020-21 application cycle.⁶ Although some programs have struggled to adapt to the new interview format, the virtual method has also created opportunities for fair recruitment.⁷

The most substantial benefit of virtual recruitment is in the elimination of financial and logistic hurdles.⁸ The average medical student spends up to $5,000 on residency interviews and away rotations.⁹ Virtual participation allows UiM students, who bear an unequal proportion of student debt, greater exposure to previously inaccessible positions.¹⁰

However, virtual applications also carry the potential to exacerbate existing inequities in recruitment. To identify and combat the unique challenges created by virtual applications, residency programs around the nation have proposed systematic frameworks that seek to redesign traditional recruitment pathways in a number of ways.⁵

Equity in Holistic Application Reviews

Traditional evaluation frameworks depend excessively on pre-conceived notions of academic merit and excellence that are not accessible to certain minority groups. In contrast, holistic reviews create more value by humanizing the applicant beyond a few standardized metrics.¹¹ Previously, programs that have utilized holistic reviews have seen an increase in both UiM applicants and resident matriculations.^12,13

To make holistic reviews fair, programs must seek to define which personal characteristics are integral into their program. A factor that is often used to discriminate against UiM applications is “fit.” The subjective nature of who “fits” into a program allows for the influence of implicit bias. Pre-defining evaluation frameworks based on the core values and missions of the program can help establish equity in the review process.¹⁴

Some experts also recommend eliminating overemphasis on the United States Medical Licensing exam (USMLE) Step -2 test scores.^15,16 “Exam score cut-offs are antithetical to the idea of increasing diversity, as these are often biased against certain populations,” explains Dr Jordan. Indeed, evidence suggests using standardized tests as an initial cut-off disproportionately screens out UiM candidates who are otherwise qualified.¹⁷

“Some programs also tend to be biased against international qualifications,” says Joel Shenker, MD, associate professor, department of neurology, University of Missouri Health System. “It can be trickier to figure out candidate performance in a different country’s medical school system, but by refusing to do that, you miss out on good people,”

A Reframe of the Interview Structure

In-person interviews provide valuable insights into an applicant’s personality and professionalism that may not be evident on a written application.¹⁸ “Video interviews lack certain nuances of communication such as shared body language, which allows you to make sense of the candidate,” explains Dr Shenker.

UiM candidates may disproportionately face the challenge of not being able to establish meaningful connections via video interviews. “Furthermore, without environmental context, the candidate cannot assess if the program is truly welcoming,” Dr Shenker adds.

To this end, some programs have established virtual social meetings as part of the interview pathway, allowing UiM applicants to interact with UiM residents.⁸ “We use gimbals to give applicants virtual tours of the hospital,” shares Dr Shenker. “This allows applicants to talk to residents and see where they work, bringing the virtual interview alive.” Programs could also consider using emerging technologies such as Sophya to create an virtual world with avatars, online games, and 3D tours to help applicants interact with current residents and faculty.¹⁹

Another option is the use of a series of virtual mini-interviews that bring together multiple candidates and residents, helping assess noncognitive skills such as interpersonal, leadership, and communication capabilities.²⁰ Although technical skills are harder to assess virtually, The Mayo clinic demonstrates an innovative video-based interview series using tasks such as knot tying and suturing.²¹

Addressing Implicit Bias in Interviewers

Unconscious and involuntary biases held by interviewers can also impede the fair judgement of candidates.¹¹ Indeed, characteristics such as accents and linguistic differences between men and women have been shown to bias candidate selection.^22,23

Programs must seek to proactively address unconscious bias in interviewers through training programs. In the emergency medicine residency program at the Boston Medical Center, an anti-bias training program was established for evaluators, which in conjunction with a holistic interview process, significantly improved program diversity; 50% of the current residents belong to UiM communities.²⁴

The Creation of an Inclusive Environment

Diverse recruitment within neurology requires the creation of an inclusive environment that meets the unique needs of virtual applications.²⁵ UiM applicants may not always have access to camera, lighting, Internet bandwidth, or the environment for ideal virtual interviews. “Applicants should not be scored negatively due to technological difficulties,” asserts Dr Jordan.

Without in-person tours that showcase diversity and inclusion, residency programs must demonstrate their priorities virtually by outlining their commitment to diversity and their anti-bias efforts and policies on the program website.¹¹ Some programs are also utilizing social media to highlight resident experiences via student organizations such as the Latino Medical Student Association.²⁶ The American Psychiatric Associations’ Black Caucus held a virtual recruitment fair that showcased diversity indicatives within residency programs.²⁷

Strategic and targeted recruitment can also help promote diversity. “Virtual recruitment presents an opportunity to expand outreach beyond the otherwise limited in-person programming. In addition to creating more accessible online programming to increase exposure to the field of neurology, residencies could specifically tailor recruitment outreach to historically Black colleges and universities, Hispanic-serving institutions, and medical schools in Puerto Rico,” Dr. Jordan suggests.

The Hybrid Future and Challenges to Overcome

“I suspect that many programs will revert to performing in-person interviews – at least in part – after the COVID-19 pandemic resolves,” says Dr Jordan. “Although I hope that programs will continue to provide virtual opportunities,” he adds. “One consideration would be continued virtual outreach and virtual interviews, while providing opportunities for applicants to visit the campus and residents in person.”

Hybrid recruitment has the potential to help maximize the benefits of both virtual and in-person applications, while allowing applicants the flexibility to choose between the two. At the University of Arizona internal medicine residency program, a hybrid “SPLIT” model helped manage costs, faculty burden, flexibility, and diversity even before the pandemic.²⁸

However, concerns remain about the uneven playing field of hybrid interviews.

“Virtual meetings are simply not equal to in-person interviews. I worry that the people who choose virtual interviews, such as international candidates, will be disadvantaged,” says Dr Shenker.

Virtual interviews are convenient and have proven to work for various residency programs. Going forward, tackling the shortcomings of this format through the concerted efforts of the neuroscience community can help meaningfully address physician diversity.

References

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