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.
1. The Importance of Diversity in Health Care: Medical Professionals Weigh In. Medical Blog | St. George’s University | The SGU Pulse. Published August 19, 2021. Accessed October 27, 2021. https://www.sgu.edu/blog/medical/pros-discuss-the-importance-of-diversity-in-health-care/
2. Gil Tommee C, Nalleballe K, Dandu V, et al. Trends in Demographics of Neurology House Staff in the United States. Cureus. Published online September 6, 2021. doi:10.7759/cureus.17754
3. Association of American Medical Colleges (AAMC). Percentage of all active physicians by race/ethnicity, 2018. Published 2019. Accessed October 28, 2021. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
4. AAMC. 2020 Report on Residents Executive Summary. Published 2020. Accessed October 28, 2021. https://www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2020/executive-summary
5. Budhu JA, Velazquez AI, Said RR, Jordan JT. Opinion & Special Articles: Maximizing Inclusiveness and Diversity Through Virtual Residency Applications and Interviews. Neurology. Published online July 15, 2021. https://doi.org/10.1212/WNL.0000000000012487
6. The Coalition for Physician Accountability’s Work Group. Final Report and Recommendations for Medical Education Institutions of LCME-Accredited, U.S. Osteopathic, and Non-U.S. Medical School Applicants. Published 2020. Accessed October 28, 2021. https://www.aamc.org/system/files/2020-05/covid19_Final_Recommendations_Executive%20Summary_Final_05112020.pdf
7. Rockney D, Benson CA, Blackburn BG, et al. Virtual Recruitment Is Here to Stay: A Survey of ID Fellowship Program Directors and Matched Applicants Regarding Their 2020 Virtual Recruitment Experiences. Open Forum Infectious Diseases. Published online August 2, 2021. https://doi.org/10.1093/ofid/ofab383
8. Dey P, Havlik JL, Kurup V, Ahuja N. Lessons from the COVID-19 Pandemic: The Case for Virtual Residency Interviews. Annals of Surgery Open. Published online September 2021. doi:10.1097/AS9.0000000000000077
9. Benson NM, Stickle TR, Raszka WV. Going “Fourth” From Medical School: Fourth-Year Medical Students’ Perspectives on the Fourth Year of Medical School. Acad Med. Published online October 2015. doi: 10.1097/ACM.0000000000000802
10. Franco I, Oladeru OT, Saraf A, et al. Improving Diversity and Inclusion in the Post–Coronavirus Disease 2019 Era Through a Radiation Oncology Intensive Shadowing Experience (RISE). Advances in Radiation Oncology. Published online September 21, 2020. doi:10.1016/j.adro.2020.09.00
11. Otugo O, Alvarez A, Brown I, Landry A. Bias in recruitment: A focus on virtual interviews and holistic review to advance diversity. AEM Education and Training. Published online September 29, 2021. doi:10.1002/aet2.10661
12. Aibana O, Swails JL, Flores RJ, Love L. Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education. Academic Medicine. 2019;94(8):1137-1141. doi:10.1097/ACM.0000000000002779
13. Marbin J, Rosenbluth G, Brim R, et al. Improving Diversity in Pediatric Residency Selection: Using an Equity Framework to Implement Holistic Review. Journal of Graduate Medical Education. Published online February 25, 2021. doi:10.4300/JGME-D-20-01024.1
14. Modest JM, Cruz AIJ, Daniels AH, et al. Applicant Fit and Diversity in the Orthopaedic Surgery Residency Selection Process: Defining and Melding to Create a More Diverse and Stronger Residency Program. JBJS Open Access. Published online November 23, 2020. doi:10.2106/JBJS.OA.20.00074
15. Williams M, Kim EJ, Pappas K, et al. The impact of United States Medical Licensing Exam (USMLE) step 1 cutoff scores on recruitment of underrepresented minorities in medicine: A retrospective cross-sectional study. Health Science Reports. Published online April 20, 2020. doi:10.1002/hsr2.161
16. Quesada PR, Solis RN, Ojeaga M, et al. Overemphasis of USMLE and Its Potential Impact on Diversity in Otolaryngology. OTO Open. Published online July 20, 2021. doi:10.1177/2473974X211031470
17. Poon S, Nellans K, Rothman A, et al. Underrepresented Minority Applicants Are Competitive for Orthopaedic Surgery Residency Programs, but Enter Residency at Lower Rates. J Am Acad Orthop Surg. Published online November 1, 2019. doi:10.5435/JAAOS-D-17-00811
18. National Resident Matching Program Data Release and Research Committee. Results of the 2020 NRMP Program Director Survey. Washington DC. Published August 2020. Accessed October 28, 2021. https://www.nrmp.org/wp-content/uploads/2020/08/2020-PD-Survey.pdf
19. Labiner HE, Anderson CE, Maloney Patel N. Virtual Recruitment in Surgical Residency Programs. Curr Surg Rep. Published online October 4, 2021. doi:10.1007/s40137-021-00302-9
20. Singh N, DeMesa C, Pritzlaff S, et al. Implementation of Virtual Multiple Mini-Interviews for Fellowship Recruitment. Pain Med. Published online April 19, 2021. doi:10.1093/pm/pnab141
21. Lund S, Shaikh N, Yeh VJH, et al. Conducting Virtual Simulated Skills Multiple Mini-Interviews for General Surgery Residency Interviews. Journal of Surgical Education. Published online May 26, 2021. doi:10.1016/j.jsurg.2021.04.013
22. Grogger J. Speech and Wages. J Human Resources. Published online April 5, 2018. doi: 10.3368/jhr.54.4.0617.8841R
23. Lindvall-Östling M, Deutschmann M, Steinvall A. An Exploratory Study on Linguistic Gender Stereotypes and their Effects on Perception. Open Linguistics. Published online November 24, 2020. doi:10.1515/opli-2020-0033
24. Asante P. Diversity in Medicine: An Innovative Approach to Resident Physician Recruitment. Published online August 18, 2020. Accessed October 27, 2021. https://www.physiciansweekly.com/diversity-in-medicine-an-innovative-approach-to-resident-physician-recruitment
25. Thatipelli S, Osude N, Youmans QR. Towards Inclusion: a Guidebook for Championing Diversity for Internal Medicine Chief Medical Residents. J Gen Intern Med. Published online April 12, 2021. doi:10.1007/s11606-021-06782-w
26. Flippen CC II. Residency Match in the Virtual World. JAMA Neurology. Published online February 24, 2021. doi:10.1001/jamaneurol.2021.0428
27. Ojo E, Hairston D. Recruiting Underrepresented Minority Students into Psychiatry Residency: a Virtual Diversity Initiative. Acad Psychiatry. Published online May 12, 2021. doi:10.1007/s40596-021-01447-6
28. O’Malley C, Bergin C, Shinar B. Virtual Residency Interviewing Strategies Webinar; 2020. Accessed November 1, 2021. https://www.youtube.com/watch?v=yDMaYY9_r5g