Keywords

LHS+ Identity: A Growing Identity Among Medical Students

As the demographics of medical students have changed throughout the last century, the OSA have had to adjust their practices to ensure equitable advising for the next generation of the physician workforce. The pre-2003 AAMC definition of underrepresented students included only Mexican Americans, Native Americans, and mainland Puerto Ricans [1]. Today, this definition has broadened including medical students from almost every country in North and South America. This broadened definition responds to the changing demography of LHS+ individuals in the US. At this moment, not only is there geographic diversity, but LHS+ families have also been in the United States for varying lengths of time. Some have been in the United States for multiple generations, while some are recent immigrants. There is also diversity in parental educational attainment and socioeconomic status, as well as intersectionality with other identities. There is no stereotypical student, or a one size fits all approach to the LHS+ student. The student affairs professional must recognize this and be agile and willing to explore the needs of their students.

Domains of Expertise: Offices of Student Affairs

Student Wellness and Mental Health: Build, promote, and manage programs, policies, and interventions to enable student wellness and mental health. Collaborate across the academic health center and the broader community to recognize and counsel students as necessary to sustain optimal health, wellness, and performance [2].

Medical student burnout is an ongoing challenge facing our workforce today, and many of these students will go on to experience physician burnout or even suicidal ideology [3]. Still, not all students will respond to the same intervention [4]. A meta-analysis by Rotenstein et al. estimates the prevalence of depression or depressive symptoms among medical students as 27.2% and that of suicidal ideation as 11.1% [5]. Programs are encouraged to “collaborate across the academic health center and the broader community to recognize and counsel students as necessary to sustain optimal health, wellness, and performance.” [5] Professional organizations such as the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) have focused efforts and developed programs on medical students wellbeing. [6, 7] Individual medical schools have developed programs ranging from student-driven initiates to approaching wellness through curricular changes. [8, 9]

There are several stressors that Hispanic medical students face in comparison to their peers. For instance, these students are more likely to have experienced high levels of acculturation stress early on in their lives, which is highly associated with depression in Hispanics [10]. Although this has not been well studied in the medical school population, it is a known phenomenon among college students [11]. Many in the Hispanic community also face increased pressures from familism, or familialismo, a centralist focus/duty to the family and family members such as—providing financial support, being a caregiver, or continuing to be present for the family despite the demands of being a student [12]. These can lead to internalized struggles or perhaps hesitancy asking for help from those outside of this family unit [13]. Lastly, institutionalized racism, such as inequitable educational or economic opportunities, and discrimination, as well as the recent anti-immigrant sentiment, may be another added stressor carried through medical training [14]. Minority students have found their race/ethnicity had adversely affected their medical school experience citing ethno-racial discrimination, ethno-racial prejudice, feelings of isolation, and different cultural expectations as causes. Students reporting such experiences were more likely to have burnout and depressive symptoms [4].

Wellness programs should be designed with these specific needs in mind to identify unique resources and avenues to explore the idea of mental health and wellness of LHS+ medical students. More research looking at the LHS+ physician and medical student workforce and the unique barriers to “wellness” and “mental health” will be crucial to develop these programs. Additionally, the OSA should hire faculty and staff that are well-versed in how to address these with novel interventions and approaches aimed at addressing the obstacles LHS+ medical students face in achieving wellness and mental health as a LHS+ medical student.

Student Professional & Career Development: Empower and guide students in setting and advancing their achievement of effective, individual-driven career and professional goals. Provide students resources and a supportive community of advisors, mentors, and staff to promote their development and transition from medical school to residency training [2].

A key element of the OSA is ushering a student through their professional identity formation as they decide what type of medicine they would like to practice, as well as the environment they would like to practice in—community practice, academic medicine, health policy, etc. The AAMC Careers in Medicine (CiM) program is a national resource that can lead a student through this process as an adjunct to the individual programs developed at each medical school [15]. A crucial part of this identity formation requires medical students to see physicians that look like them as role models to envision themselves in the various clinical and faculty positions.

As previously stated, the LHS+ population is fast-growing, therefore, the LHS+ workforce will need to grow. Thus, here needs to be more investment in recruiting and maintaining LHS+ students in academic settings [16]. As an example, the representation of LHS+ physicians is lacking across specialties, with the lowest representation in ophthalmology, radiology, radiation oncology, and otolaryngology. [17,18,19,20] Unfortunately, programs such as the CiM provides little content tailored to students underrepresented in medicine. The CiM information is primarily focused on specialty choice and less so on having students develop a fuller appreciation of career options, such as faculty or senior administrative positions, government, or business. This is particularly relevant when you consider that LHS+ are not only underrepresented in certain medical specialties, but also in academic medicine. In 2020, among medical school faculty, solely 5.9% are of Latino, Hispanic, or of Spanish identity, and this is inclusive of the medical school faculty from the four medical schools in Puerto Rico [21].

Increasing LHS+ medical student awareness and interest in academic medicine careers can eventually yield a higher proportion of HS+ faculty and leaders who can staff or support the OSA responsibilities. Programs such as Building the Next Generation of Academic Physician (BNGAP Inc., www.bngap.org), a national organization focused on diverse medical students and resident awareness and interest in academia, provides the resources to explore further and potentially embark on an academic medicine career. [22] The Latino Medical Student Association and BNGAP have developed curricula to raise Hispanic trainees’ awareness of, interest in, and preparedness for academic careers, including engagement and leadership opportunities with the Office of Student Affairs [23].

Beyond medical school, there is little research showing strategies to promote a successful transition from medical school to residency training that is unique to the LHS+ population. One could speculate, however, that by including LHS+ faculty in the conversation throughout the transition into the residency, these students will be better equipped and supported to join the physician workforce while celebrating their unique identity.

Student Academic progression: Build, promote, and leverage resources, policies, programs, and interventions to enable successful academic progression for all students. Collaborate across the academic health center and the broader community to help students proactively address and mitigate risks and issues necessary to optimize their educational experience and growth [2].

Academic advising is also a key component of the OSA. Medical students will enter medical school with different degrees of exposure to the basic sciences, and many may be first-generation college students. Medical school academic support varies throughout the country. Some will provide pre-matriculation programs that target students underrepresented in medicine (UiM) [24,25,26,27].

One aspect of academic progression is that of standardized exams. UiM students consistently score lower on standardized exams compared to white and Asian students [28]. Experts widely accept that these differences are due to the consequences of structural racism, stereotype threat, and inequities in education, housing, and household income [28, 29]. On the whole, UiM students have more limited financial means. They are thereby unfairly disadvantaged compared to others who can afford the expensive test preparation services and mentoring that are beneficial to test-takers [30, 31]. Cumulatively, these factors may adversely influence UiM students‘performance on high-stakes examinations such as the Medical College Admission Test and the USMLE Step 1. This unfairly limits their chances of matriculating into medical school or gaining acceptance to a residency program in a preferred specialty.

Another area worth exploring is the variability in clinical grades, depending on your ethno-racial identity. Clinical grading disparities have been studied and show favor for white students when compared to underrepresented minorities. Differences have been found in the quality of narrative evaluations associated with UiM status [32]. Also, there are disparities in clinical grading and medical school letters of evaluation [33]. The objective and subjective value or effect of LHS+ medical students’ clinical evaluations when they are tasked or voluntarily agree to use their medical Spanish or cultural proficiency to care for LHS+ patients is unknown. More work needs to be done to hone in on the root causes of and address the disparity.

Student Diversity and Inclusion: Position diversity as a key driver of educational excellence, a diverse physician workforce, and ultimately equitable health care for all. Advocate for and foster an inclusive, engaging environment to optimize student performance and experience [2].

Once LHS+ students are recruited into medical school, having an inclusive and engaging environment to support their academic, professional, and personal development is crucial. It is not only important to showcase diversity and inclusion in the recruitment process, but also that it is an integral part of student life upon matriculation to medical school. Medical schools seek to accomplish this in a variety of ways, including specialized programming and through offices of student diversity and inclusion.

Offices of student diversity may be under the OSA or separate entities. Their purpose is multifold and includes the recruitment and retention of students that are underrepresented in medicine. These offices are typically staffed by faculty that are UiM and provide support for underrepresented students. Specific programming by diversity offices, as well as the medical school in general, can celebrate the unique skill set and experiences of LHS+ medical students and physicians in a variety of ways such as: organizing LHS+ faculty speaker events, teaching the history of LHS+ in medicine, or perhaps a social media campaign during Hispanic Heritage Month. While these examples are not all-inclusive, they present the opportunity for programs to be advocates and allies to LHS+ medical students, and thus, enhance their medical training experience.

Student Financial Assistance: Provide medical students, applicants, and graduates with sufficient financial aid and effective debt management counseling, education, and resources. Establish mechanisms and recognize opportunities to enable students to minimize medical education debt [2].

The cost of medical school continues to rise every year and can be more than $100,000 for tuition alone [34]. The need for financial assistance is needed for two main reasons. First, tuition rates continue to increase every year, and second, Hispanic medical students are more likely to come from lower socioeconomic status than their white counterparts. The majority of Hispanic medical students come from households with a combined gross income of less than $50,000 per year than their white and Black or African American peers [35]. For the 2019–2020 school year, the average cost for 1 year of medical school was $37,556 for residents and $61,858 for non-residents at public medical schools. Not surprisingly, private medical schools’ costs were even higher at $60,665 for a resident and $62,230 for a non-resident [35]. Thus, Hispanics pursuing medical education will require funding from loans that will inevitably lead to long term debt. Additionally, another group that requires unique assistance are DACA (Deferred Action for Childhood Arrivals) students. These students are not eligible for federal funding and have limited options for financing their medical education.

LHS+ students not only face significant barriers in affording the application fees for medical school, but face additional burdens affording the increasing costs of medical education. The OSA should provide appropriate counseling and debt management resources that are unique to the LHS+ medical student population. Additionally, the data around these resources (minimizing medical education debt) needs to be documented and shared to standardize the best approach to help this student population in financing their education. There are a variety of financing options, and schools should hire financial counselors that are well versed in guiding LHS+ students through debt management.

Medical School Recruitment & Admission: Develop and execute effective, data-driven pipeline programs and admission policies, processes, and practices to ensure a broadly diverse and well-rounded student body that advances the mission of the medical school [2].

The significance of this area is evident in the definition outlining the purpose of an inclusive and engaging environment—to optimize student performance and experience. There has been some improvement in the recruitment of a more diverse workforce over the last century. However, the rate at which LHS+ medical student enrollment has grown is not sufficient enough to compare to the growth that the LHS+ population has experienced on the national level. Hispanics are now the largest non-white racial or ethnic group in America (approximately 19%) [36], yet only 12% of allopathic medical students and 5.8% of physicians are Hispanic [37]. There needs to be monumental changes to the recruitment of LHS+ medical students. Even more alarming, the percentage of allopathic LHS+ medical students has only changed from 4.9% in 1980 to only 12.0% in 2022, reflecting the need for improved recruitment and retention strategies. As mentioned previously in this chapter, the future physician workforce will need to address the unique challenges that LHS+ communities experience. It will require investing in physicians with similar lived experience. There needs to be a more significant push and investment in pathway programs that will ultimately increase the number of LHS+ applicants so that more can enroll in medical school. Additionally, the recruitment efforts need to expand beyond the college years to cover primary education and exposure to the medical field.

Student Records Management: Interpret, communicate, and act in accordance with the laws, regulations, and school standards for maintaining the academic records of students. Establish and oversee processes to ensure the ongoing integrity, security, and fulfillment of information needs [2].

The OSA work closely with the Offices of the Registrar on student records management. These offices maintain student records, process course registration, provide documentation to support application and licensure processes, and maintain course catalogs. Also, they develop plans and policies that protect student privacy. As stewards of student data these offices ensure the enforcement of guidelines under the Family Educational Rights and Privacy Act (FERPA) which is the Federal law that protects the privacy of student education records. FERPA protects student records offices from divulging information such as DACA or other immigration status.

Unit Operations Management: Establish, execute, and allocate resources necessary to support strategic and programmatic goals and priorities and overall direction of student affairs. Lead efforts to maintain ongoing alignment of services and programs with the dynamic needs of students and the mission of the school [2].

The concept of unit operations management brings together the idea of organizing all medical offices that provide student services establish a learning environment conducive to the success of all learners. In regards to the LHS+ student, it involves gathering identifying barriers and developing best practices. All departments, and the school as a whole, must be held accountable to pre-established metrics of success. As strategic plans are designed, issues of diversity and inclusion should be a priority.

Conclusion

Like so many times before, medical school education will need to adjust to the ever changing landscape of a more diverse student population. As we advance into a new diverse physician workforce, we must understand how to support this workforce throughout the stages of training. The eight areas of expertise outline a clear direction for the OSA and Deans to embark on as we move towards a new generation of physicians. Given LHS+ individuals are the largest ethnic/racial minority, the OSA must begin to address the unique experience of LHS+ students and acknowledge the unique experiences that each UiM group experiences throughout medical training. As the offices devoted to overseeing and enhancing the medical student experience, prioritizing research, and innovation in the LHS+ medical student experience is crucial as we move into the next decade.