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Shaking up residency program admissions

Cary B. Aarons, MD
May 14, 2019

One surgical program managed to double its percent of underrepresented residents. It took three fundamental steps — and a willingness to upend their whole approach.

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Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

As the first African American general surgery program director in the history of the department of surgery at the Perelman School of Medicine at the University of Pennsylvania, I consider myself a change agent.

But change comes slowly, and my road to becoming a surgeon wasn't always easy — and would have been much harder without diverse role models. As a young medical student at Howard University College of Medicine, I was inspired by two outstanding professors: LaSalle D. Leffall, MD, chairman of the department of surgery and the first African American president of the American College of Surgeons, and Debra Ford, MD, who was compassionate and unflappable while working as a prominent colorectal surgeon in a male-dominated department. I appreciated not only their great surgical expertise but also the leadership that they modeled, especially since they are from backgrounds underrepresented in the field of surgery.

These two figures taught me what was possible and that diversity matters. It is in large part because of them that I now aspire to weave a mindful commitment to diversity into the residency recruitment process at Penn.

Diversity remains an elusive goal, particularly in the surgical specialties, which have the unfortunate distinction of achieving the least progress in increasing diversity in the medical workforce.

Diversity in medicine is essential, and evidence supporting its value continues to grow. For example, physicians from backgrounds underrepresented in medicine (UIM) are more likely to work in minority communities and medically underserved areas. Women doctors tend to provide more patient-centered and informative consultations. And African American and Latino patients are more likely to feel comfortable with UIM physicians, resulting in greater patient satisfaction, compliance, and participation in clinical research.

Yet diversity remains an elusive goal, particularly in the surgical specialties, which have the unfortunate distinction of achieving the least progress in increasing diversity in the medical workforce.

Here at Penn, we’ve strengthened our diversity efforts and made progress in increasing diversity in our surgical training programs. We are proud of what we have achieved so far, and we hope it inspires other residency programs to take similar steps.

Currently, many surgical residency admissions programs rely fairly heavily on objective metrics, including U.S. Medical Licensing Examination (USMLE) scores, clerkship grades, and election to the national medical honor society Alpha Omega Alpha (AOA) — albeit coupled with such evaluations as letters of recommendation. This is problematic because metrics like USMLE scores haven’t been shown to consistently predict clinical skill acquisition, and importantly, may hinder much-needed diversity.

To tackle such concerns, our surgery department, under the guidance of Graduate Medical Education Director for UIM Affairs Paris Butler, MD, recently adopted a robust approach to resident recruitment and selection. Previously at Penn, 23% of the medical student body was from UIM backgrounds — but only 7% of our surgical residents were UIM residents. We were determined to change that and set out to do so with a three-part plan.

Diversity . . . is a means to excellence. Without it, we will not be able to train true leaders or effectively promote collaborative learning, teamwork, and culturally competent patient care.

The first facet of our approach was to attract more UIM medical students to our surgery program. We offered month-long surgical clerkships to fourth-year UIM students to help them connect with our program and staff. We advertised the clerkships nationally and then provided accepted students with stipends to help cover lodging and travel expenses.

The second aspect was to implement the holistic review of residency applications, with an increased focus an applicant’s experiences, talents, and capabilities and a deemphasis of USMLE scores. In fact, our application reviewers are blinded not only to USMLE scores but also to grades and AOA status.

We chose instead to emphasize characteristics that resonate with our department’s mission: leadership, teamwork, altruism, intellectual curiosity, and research activity. This approach provides a more comprehensive view of applicants, including their inherent attributes, their use of available resources, and the duration and depth of their relevant experiences. This broader lens magnifies the many ways an applicant’s talents may enrich the learning environment, improve research, and increase culturally competent patient care.

To enhance holistic review, we also expanded the selection committee. Previously, only the program director and a few integral staff were involved, but now we include 23 faculty members and senior residents, 43% of whom are women. We also began providing committee members with resources and training on holistic review as well as on unconscious bias. In addition, we encouraged members to attend implicit bias training, and we now remove an applicant’s photo and ethnicity from their application to help avoid unconscious biases.

We chose to emphasize characteristics that resonate with our department’s mission: leadership, teamwork, altruism, intellectual curiosity, and research activity.

Finally, the approach involved targeted outreach with the assistance of members of the university's Alliance of Minority Physicians (AMP) — a UIM-focused staff, junior faculty, and medical student support and mentorship network. AMP members contacted UIM surgical residency applicants before and on their interview day as well as afterwards in cases when the applicant requested follow-up. This helped provide additional perspectives about Penn and ensured that an applicant's questions could be answered outside of the formal interview process.

The approach is paying off. In 2014, 12.1% of matched candidates in our surgical residency programs were UIM. In 2017, that number rose to 23.5%. While preliminary, we’re excited about these results, and we look forward to seeing how we can continue to improve.

Fortunately, Penn is not alone, as a growing number of surgery programs have adopted holistic review in part or in whole. In addition, several other medical schools and residency programs have been experiencing success with holistic review. Still, our community needs to do more work, including coming together to identify best practices for recruitment and selection in surgical residency programs.

This country needs diverse physicians, and surgical programs can help lead the way. Diversity in all its forms is a means to excellence. Without it, we will not be able to train true leaders or effectively promote collaborative learning, teamwork, and culturally competent patient care. Without such efforts, the health of our nation will suffer.

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