Keywords

Nota bene: This book uses “LHS+”, however, the data may use “Hispanic”, “Latino,” “Latina,” “Latinx,” “Latine”, “Latin American,” “Spanish Origin” or lump these groups into a larger category with African Americans and Native Americans. Here, “Underrepresented Racial Minority” (URM) is used in reference to folks in the aforementioned larger category. Other nomenclatures exist, but the data used in this chapter primarily used the term URM.

Oddly, it is easier to end a discussion on the state of LHS+ in Graduate Medical Education (GME) than to begin one. A literature review will reveal a myriad of terms, endpoints, and solutions, but where does the story begin? A sociologist may begin with the SAT, universities, and GPAs. Historians would look at immigration and population movements. As GME does not exist in a vacuum, both starting points have equal merit. The preceding chapters are as important as these pages to understand the full picture, and we pick up where our colleagues have left off—medical school or Undergraduate Medical Education (UME).

According to the Accreditation Council on Graduate Medical Education (ACGME), in the 2018–2019 year, LHS+ individuals consist of 5.3% of residents and fellows [1]. The AAMC reports that in 2019 11.0% of US medical school matriculants identified as LHS+ [1, 2]. More concerning are specialty areas where the percentage of LHS+ individuals is critically low, such as radiology, orthopedic surgery, and otolaryngology [3]. Some tout Latin American graduates as a potential solution, but the data is scarce. The Educational Commission for Foreign Medical Graduates does not release regular reporting on the racial and ethnic composition of internationally trained physicians aspiring to enter residencies and fellowships. A 2008 study reported that ECFMG-certified Foreign Medical Graduates (FMG’s) are more likely to be LHS+ (about 8%) than graduating U.S. seniors and about 1 in 5 of those LHS+ FMG’s are U.S. citizens [4]. The data admittedly appears promising. The caveat is that ECFMG certification does not guarantee a residency position, and the ACGME does not have published data for the race and ethnicity of the IMG’s in GME. Therefore, we cannot tell if LHS+ FMG’s are linguistically bound to Puerto Rico’s GME programs or even how many of them make it to residency programs. In other words, all we can do is postulate on their potential impact based upon 15–20-year-old data. Thus, constrained by the data, our focus will be on graduates from LCME-accredited institutions.

The path to GME invariably starts with the choice of medical school. More prestigious medical schools can be an asset, especially for students who are pursuing GME training in specialties where programs are scarce and extremely competitive. US News and World Report ranks medical schools by primary care and by research output. Medical students get ranked not only by quartiles based on test performance but also by taking a series of national standardized tests. The first one is the United States Medical Licensing Examination (USMLE’s) Step 1 examination. This is where the first true “weeding out” process for GME begins. A score of 270 opens the doors to the most coveted and lucrative specialties, while a score below 200 can shut candidates out. Considering LHS+ and underrepresented racial minority (URM) students’ USMLE Step 1 score lags behind their peers, this potentially translates into fewer career opportunities [5]. Failure of passing USMLE Step 1, though not very common, is higher also for LHS+ and URMs. A study has shown that failure to pass Step 1 on the first attempt leads to a higher likelihood of training in primary care specialties; intent to practice in underserved areas, and taking more than 4 years to graduate from medical school [6]. In this study, the relative risk of not passing Step 1 on the first attempt was 7.4 for LHS+ individuals. Therefore, LHS+ individuals and other URM students are being excluded from GME programs before we assess their clinical skills and knowledge. As Step 1 score reporting changes to pass/fail in January 2022, the National Board of Medical Examiners (NBME) hopes to decrease GME’s reliance on Step 1 scores as a quality metric for candidates [7].

As the focus shifts away from Step 1, a student’s performance on clinical rotations (clerkships) becomes more prominent; for LHS+ individuals, this may still represent a disadvantage. Studies have shown that LHS+ and URM students are less likely to receive Honors grades than their peers [8]. Clerkship grades are partially subjective and vary between institutions, so the evaluation comments are supposed to serve as a clearer indication of the candidate’s professional and clinical identity. On clerkship evaluations, LHS+ students are less likely than non-URM peers to be described as “superior” or “integral.” [8] Unfortunately, LHS+ and URM students are more likely to have more negatively coded descriptors used in both their clinical evaluations and the Medical School Performance Evaluation—a comprehensive evaluation prepared by the school to send as part of a student’s residency application [9, 10]. Understandably, many reviewers fall into the trap of associating those adjectives to lower clinical skills or knowledge level. However, these words are in a pool of over 70% of descriptors more common to non-URMs that have no relation to clerkship performance [8]. Unless we accept the notion that student competency is related to LHS+ ethnicity and/or race, we must recognize that clerkship grades and evaluations are potentially biased and cannot be relied upon as purely objective measures of LHS+ and other URM students’ clinical performance.

Beyond recognizing USMLE and clerkship grades as biased, institutional leaders should consider the question “How ought GME Program Directors best assess the LHS+ medical student?” The answer is to do so the same way we should evaluate all candidates—holistically. Holistic reviews give a balanced consideration of academic metrics, experiences, competencies and attributes [11]. It aims to assess applicants based on their unique backgrounds. The process is applied equitably across the entire applicant pool. At all times, the organization’s mission and vision are kept aligned with this holistic review, with the goal of finding applicants who will meaningfully contribute to the institution’s mission. Table 12.1 describes in more detail some of the elements in the holistic review process.

Table 12.1 Elements of the Holistic Review Process
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The holistic review expands the set of criteria by which applicants are reviewed. In standard reviews, excessive relevance is given to objective metrics of academic excellence, such as Alpha Omega Alpha (AOA), the medical student honor society, or Gold Humanism Society recognition. For example, AOA status is highly valued by many residency programs. URM students are underrepresented in AOA Chapters across the nation [12, 13]. As outstanding academic performance is the foremost criterion for AOA membership [14], racial and ethnic grading disparities present an unintended dilemma. URM students are less likely to receive a grade of Honors for clerkships (a common component of AOA membership criteria) [8], but the USMLE examinations have been viewed as an opportunity to even the score. Outside the top quartile of USMLE Step 1 scores, LHS+ students are less likely to be inducted into AOA than their White colleagues [12]. Even setting aside the debate of racial and ethnic bias in standardized testing, we still see inequality. Therefore, until AOA membership selection is holistically reformed, its use as an applicant screening criterion disadvantages URM students—who already have difficulty getting through the screening process [15]. In at least one specialty-specific survey, URM minority students were interviewed in fewer programs than their non-URM counterparts (15 vs 20) [16]. The study did not differentiate between interviews offered vs interviews attended, but it still shows a significant difference in the number of programs where an URM candidate has the opportunity to interview.

The issues LHS+ individuals face with GME recruitment do not end with the application screening process and the interview invitations but continue into the ranking of applicants. Many in academic medicine are aware of “fit”—referring to how well a candidate would mesh with the current culture of a program. If a program lacks diversity, then placing added value on candidates who match that profile serves only to perpetuate the lack of diversity [17]. Of course, the assumption is that the reader values or (at the very least) is intrigued by the concept of diversifying GME. Though one might think that program directors value diversity when ranking candidates, half of the surveyed program directors do not view a candidate’s URM status as at least “somewhat important.” [18] This is but a small part of the undervaluing of areas in which LHS+ applicants excel. About 70% of program directors did not value bilingualism during resident recruitment [18], which is one of the benefits of LHS+ diversity. Even if LHS+ candidates have more leadership and volunteer experiences than their URM counterparts, those attributes are less important to program directors and, thus, unlikely to help them match [19]. Authors have noted that URM candidates will often have more structured research experiences than non-URM candidates; however, non-URM candidates were more likely to publish—another example of how LHS+ candidates can end up undervalued [20]. Preventing structural components that undervalue URM candidates is key to the components of the ACGME standard on diversity:

The program, in partnership with its Sponsoring Institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present), faculty members, senior administrative staff members, and other relevant members of its academic community [21].

The ACGME requires programs to go beyond diversity fairs. The reality is that GME programs must change how they educate residents to accommodate a more diverse program. Relying on old teaching methods ignores the needs of these new trainees and likely contributes to the misconception that LHS+ applicants may not be as strong as their colleagues. There are no traditionally LHS+ medical schools in the continental United States; however, successful training models can be found at historically Black medical schools. Morehouse School of Medicine used a familial teaching environment to increase student engagement leading to the MCAT underpredicting URM students’ USMLE Step 1 scores; the important discovery is that the close faculty-trainee relationship was the key to the latter’s success [22]. In other words, by changing the institution’s approach to the culture of medical education, the faculty facilitated trainees’ success. Medicine has discussed culturally competent care, but the time has come to discuss culturally competent medical education.

LHS+ trainees are asked to assimilate to the culture of medicine, without developing their cultural identities in medicine. The United States is home to the second-largest Spanish-speaking population in the world [23]. Yet, only one LCME-accredited medical school (outside of Puerto Rico) requires medical Spanish for graduation [24]. Language is but one of many cultural contributions LHS+ trainees contribute to a program and patients across the United States. Understanding nuances in patients’ cultural belief systems can be the difference between an unnecessary Psychiatry consultation and pausing to listen and address patients’ concerns. Although the mainland United States is beginning to address Medical Spanish and other LHS+ cultural contributions, there are LCME-accredited models for our institutions to emulate.

Puerto Rico, a colony of the United States, has four LCME-accredited medical schools that combine to graduate about 300 students each year [25]. Each school serves as an example of a homogenous faculty and student body of LHS+ individuals. Research, service, and innovations are conducted within the patient population’s culture; thus, learning from Puerto Rican medical schools, residencies, and fellowships is integral as mainland U.S. schools endeavor to culturally develop LHS+ physicians. One of the benefits of rotating at the LCME-accredited schools in Puerto Rico (in addition to a high-quality, hands-on clinical education) is the ability for LHS+ students in the mainland to hone Spanish as an academic language—as opposed to a social language used at home [26]. In turn, greater partnerships with Puerto Rican schools can dispel the misunderstanding amongst residency programs that these U.S. MD students are foreign medical graduates [27]. These candidates present an unique opportunity to diversify a program while training physicians more likely to work in one of the most medically underserved areas in the United States [28]. Additionally, Puerto Rico suffers from a deficit of subspecialists—partially due to the loss of physicians to higher wages in the U.S. and the lack of fellowship programs on the island [28]. Thus, the training of Puerto Rican students and residents can help to decrease healthcare disparities in both the United States and Puerto Rico.

Programs have developed some effective models for marketing, recruiting and matching LHS+ individuals and other URM applicants [29]. There are two ways to categorize the strategies presented in the literature: active or passive. Active recruitment primarily utilizes finances and/or man-hours to recruit. While, passive recruitment primarily utilizes a change in how candidates are selected for interview and ranking. Models vary widely; however, intentionality and unconscious bias training are ubiquitous.

Unconscious bias training is key to mitigating the subjective nature of GME recruitment and to subsequently identifying qualified LHS+ candidates. This is essential for passive recruitment models, which depend on a paradigm shift. McGovern Medical School at UTHealth’s Internal Medicine Residency matriculated more URM candidates (without increasing URM applicants) through a passive recruitment model [11]. Their model began by highlighting the diversity of Houston, TX; the program’s commitment to diversity; and had URM faculty interact with candidates. Then, the program tweaked the interview questions from the familiar “tell me about yourself” to standardized questions that were aimed at identifying their most important and desirable characteristics (e.g., teamwork, problem-solving, and adaptation to change). Finally, the program redesigned interview criteria to be inclusive of areas in which URM candidates excel – commitment to underserved communities, leadership roles, Spanish fluency—all which are representative of the Houston population (about two-thirds of Houston, TX identifies as Black or Hispanic) [30]. Finally, the program decreased the emphasis on the USMLE scores. The success of this program proved the path to diversity need not depend on large funding sources or outreach to more LHS+ individuals. The key, as always, is to value the talent present in candidate pools. This model may not work for everyone. Passive models are great for programs who have a diverse talent pool but lack diversity in their house-staff. The paradigm shift will open the door for LHS+ individuals and other URM applicants who have already been knocking.

For programs who struggle to attract URM applicants or programs that have a limited applicant pool, an extra investment is necessary. Active recruitment modalities allow programs to find and attract applicants who otherwise may not have considered training with them. Denver Health Residency in Emergency Medicine followed guidelines published by the Council of Residency Directors in Emergency Medicine – which were developed in response to EM’s diversity falling behind other specialties with regards to diversity. There were three recommended interventions:

  • Scholarship-based Externship Programs

  • Funded Second-look Events

  • Involvement of URM faculty during recruitment

These interventions resulted in an increased number of applications from URM candidates and the number of URM matriculants [31]. The costs associated with active recruitment will depend on the program and the institution. Collaboration between departments and applying for grants through organizations, such as the Hispanic Centers for Excellence, can help alleviate the financial burden of active recruitment. Additionally, there are novel ways to conduct active recruitment at lower costs. The Ohio State University’s Cardiovascular Medicine Fellowship Program ran active recruitment by leveraging an URM faculty member’s Grand Rounds invitations at diverse residency programs to identify and court URM residents. The URM faculty member also committed to mentor the residents as fellows. The rest of their recruitment was passive; however, the authors noted an increase in URM applicants and matriculants [32]. A program’s ability to execute this form of active recruitment would be dependent upon the presence of a willing URM faculty, which may more than likely be scarce. Engaging in virtual mentoring of medical students is another way to do active recruitment at a low cost. Many national organizations have programs for virtual advising and virtual mentoring. Finally, no opportunity should go unused. When program faculty are participating in regional and national meetings, they should participate in any recruitment activities, such as residency and fellowship fairs. Students should do the same and pay attention for specialty-specific activities happening on campus or in their cities; making sure to attend and network at local meetings when possible. Table 12.2 describes some important activities for LHS+ students during medical school that can help maximize their chances of a successful match.

Table 12.2 Actions and activities to succeed in applying to GME programs
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Given the dearth of LHS+ trainees in GME, it is imperative to ensure that a concerted effort is made to retain those we have and get them into fellowships or, more importantly, careers in academic medicine. The retention of trainees is tied to the career satisfaction and the experience of being a minority. The data reveal high rates of attrition amongst Hispanic residents [33]. When correlated with research revealing that being as Hispanic is associated with an increase relative risk of dissatisfaction with specialty [34], several questions arise. There are no published investigations into whether or not Hispanics have matched into their desired specialty or have changed the specialty to which they intended to apply while in medical school. If this is due to poor match outcomes or applicant screening, then it is a tragedy. Given data that URM residents perform no differently from their non-URM colleagues in objective clinical assessments [35], issues in recruitment may have unnecessarily (and unintentionally) negatively impacted the careers of LHS+ physicians.

Premature departures from a training program are costly. Recruitment is a huge investment, and the loss of a trainee results in additional workloads for other residents and a lower program morale and poor career outcomes for the dismissed resident. These factors, which limit inclusivity, are accompanied by other potential contributors to attrition. Hispanics and other URM residents report experiencing microaggressions and other racist incidents during training and being forced to serve as racial/ethnic ambassadors [36]. While workplace incidents are common across professions and backgrounds, Hispanic trainees may lack confidants who can share their burdens and serve as release valves. URM residents are less likely to use resident wellness services out of fear that the use of the services will not be fully confidential [37]. The solution to these issues is more inclusivity.

LHS+ students and residents are as capable as other trainees. When discussing challenges LHS+ individuals face, it is done in the context that they have graduated from LCME-accredited medical schools, passed the USMLE, and are fully acknowledged academically. Thus, the obstacles stem not from the applicant but from a system that organically evolved to accommodate a homogenous socioeconomic demographic. Formal medical education in the United States took off in the Gilded Age (late nineteenth Century) and transformed dramatically well into the mid twentieth Century [38]. During this time period (see Fig. 12.1 below), the U.S. government was at war with Native American tribes [39]; Jim Crow and segregation of African Americans were in full effect [40]; and Hispanics were being lynched and sterilized [41,42,43]. In other words, certain populations were conspicuously absent from the inception and evolution of medical education in the United States and are thus unsurprisingly underrepresented in the field created in their absence. Please note this is not a condemnation of medical education, but a call for reform to allow all Americans to thrive.

Fig. 12.1
A timeline. African slave trade, between 1525 and 1865. Most U S medical schools founded, 1805 to 1980. Residency programs founded, 1890 to 2020. Hispanic women sterilization, 1930 to 1980. Lynching of Mexican-Americans, 1850 to 1930. American-Indian wars, 1790 to 1890. Jim Crow laws, 1880 to 1960.

Development of medical education in the context of concurrent U.S. historical events

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Residency and fellowship programs can take steps to help LHS+ residents excel during residency. The solutions to developing LHS+ residents come from the residents themselves. URM residents suggested in-person, practical trainings to address racism and microaggressions and for programs to work to eliminate the fear of reporting incidents [44]. Additionally, residents have enjoyed the opportunity to serve as mentors to URM students – which has shown to increase their interest in academic medicine [45]. Hispanic and other URM residents have an increase in satisfaction and interest in academic medicine when they have URM faculty mentors [46]. The importance of mentorship cannot be overstated throughout this process. The retention, satisfaction, and (most importantly) success of LHS+ residents all hinge upon mentorship.

Throughout this book, it’s clear URM faculty hold diversity and inclusion together at every level. The issue is academia (and medicine as a whole) lacks a proportional amount of URM physicians to handle the load. Currently LHS+ inidividuals represent a disproportionately low 5.8% of all physicians and 6.3% of physicians in academia [47, 48]. Of LHS+ individualsphysicians with academic appointments, 65% hold non-tenured positions, 19% are Associate Professors, and 16% are Professors [49]. These paltry numbers are going to be the backbone of diversity and inclusion efforts that support the training of LHS+ physicians. Thus, the recruitment and retention of LHS+ academic physicians will be essential to all levels of LHS+ trainees.

Recommendations on how to recruit LHS+ faculty are scarce. The availability of published research into LHS+ recruitment decreases as the level increases from UME to GME to faculty appointments. Few institutions have implemented programs to recruit LHS+ and URM physicians to their faculty; disappointingly, even fewer have tracked and published statistics regarding their URM faculty recruitment programs [50]. The jury is still out. Some programs have yielded success [50], while others have not [51]. The U.S. medical schools with URM faculty recruitment programs tended to be higher ranked and to have larger faculties; additionally, those that reported success instituted programs with mentoring, career development, social climate, and financial support components [50].

The reality is that it will take both time and money to recruit LHS+ faculty. Mentorship is important throughout anyone’s career; however, LHS+ physicians will be aware of the stigmas associated with being an URM in academic medicine—especially the disparity in promotions to tenured positions and Associate Professor to Professor [20]. In the recruitment of LHS+ faculty, programs are working against decades of inequality. Even if Rome were built in a day, it was certainly not built for free. If institutions cannot shoulder the financial burden, then the federal government has an opportunity and an obligation to fund LHS+ faculty appointments, which have the additional public health benefit of attracting in more clinical study subjects from the LHS+ community [52].

Hope comes from within. Time and time again, the literature demonstrates that research and authorship in medical school and residency will mitigate promotional disparities [20]. In essence, having early career opportunities for mentorship and publishing will cultivate future generations of LHS+ academic physicians. Although medical schools and GME programs may lack formal programs to address the aforementioned revelation, LHS+ physicians and trainees are leading by example and uniting to close these gaps. In 1994, the National Hispanic Medical Association (NHMA) was founded as a dedicated network of Hispanic physicians to provide advocacy, education, leadership development, and networking [53]. In 2010, Building the Next Generation of Academic Physicians (BNGAP Inc.) was founded to increase diverse trainees’ awareness of, interest in and preparedness for academic careers; a novel approach to increase diverse GME staff and leaders [54]. These professional societies are invaluable grassroots networks through which mentors and mentees can be identified. They may serve to identify solutions and serve as points of outreach, but there is no sole intervention to close the gaps. Diversity and inclusion will require efforts at all levels to achieve parity.