Faculty Bibliography

IMPORTANCE:Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education. OBJECTIVE:To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents. DESIGN, SETTING, AND PARTICIPANTS:This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022. MAIN OUTCOMES AND MEASURES:The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes. RESULTS:The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training. CONCLUSIONS AND RELEVANCE:In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

Importance:Diverse research teams are critical to solving complex health problems and producing high-quality medical research. Objective:To examine the associations of student sex and racial and ethnic identity with publication rates during medical school. Design, Setting, and Participants:This cohort study assessed individual-level data of US MD graduates from medical school who matriculated in academic years 2014 to 2015 and 2015 to 2016. Data were obtained from the Association of American Medical Colleges and analyzed from October 2021 to January 2022. Main Outcomes and Measures:Outcomes of interest included students' self-reported participation in unique research experiences, number of publications, and computed publications per research experience. Poisson regressions were constructed to determine the association of sex and racial and ethnic identity with research outcomes using adjusted rate ratios (aRRs). Results:Among 31 474 graduates, 15 159 (48.2%) identified as women and 4344 (13.8%) identified as underrepresented in medicine by race and ethnicity (URIM; including American Indian, Alaska Native, Black, Hawaiian Native, Hispanic/Latinx, and Pacific Islander individuals). Students who attended National Institutes of Health (NIH) top 40 research-ranked schools reported higher number of research experiences and publication counts, resulting in a higher publication rate compared with students from non-top 40 schools (median [IQR] 1.60 [1.00-3.00] vs 1.25 [0.50-2.33]; P < .001). Women reported a higher number of research experiences than men but a significantly lower number of publications (top 40 schools: aRR, 0.89; 95% CI, 0.87-0.90; non-top 40 schools: aRR, 0.93; 95% CI, 0.92-0.95). This resulted in a significantly lower publication rate among women (top 40 schools: aRR, 0.85; 95% CI, 0.83-0.86; non-top 40 schools: aRR, 0.91; 95% CI, 0.90-0.92). Compared with White students, Asian students had higher publication rates at both NIH top 40 schools (aRR, 1.10; 95% CI, 1.08-1.12) and non-top 40 schools (aRR, 1.07; 95% CI, 1.05-1.08), while lower publication rates were reported among Black students (top 40 schools: aRR, 0.83; 95% CI, 0.80-0.86; non-top 40 schools: aRR, 0.88; 95% CI, 0.85-0.95) and Hispanic students attending non-top 40 schools (aRR, 0.93; 95% CI, 0.90-0.95). Conclusions and Relevance:These findings illustrate that inequities in the physician-scientist workforce began early in training and highlight key areas for intervention, such as funding support and mentorship training during undergraduate medical education, that may promote the future success of a diverse physician-scientist workforce.

Importance:Disparities in medical student membership in Alpha Omega Alpha (AOA) are well documented. Less is known about Gold Humanism Honor Society (GHHS) membership and it remains unknown how the intersection of different identities is associated with membership in these honor societies. Objective:To examine the association between honor society membership and medical student race and ethnicity, sex, sexual orientation, socioeconomic status, and intersection of identities. Design, Setting, and Participants:This cross-sectional study analyzed data from Association of American Medical Colleges data collection instruments. The study included all students who graduated from Liaison Committee on Medical Education-accredited US medical schools from 2016 to 2019 and completed the Graduation Questionnaire. Data analysis was conducted from January 12 to July 12, 2022. Main Outcomes and Measures:Likelihood of AOA and GHHS membership by student race and ethnicity, sex, sexual orientation, childhood family income, and intersection of identities. Results:The sample of 50 384 individuals comprised 82 (0.2%) American Indian or Alaska Native, 10 601 (21.0%) Asian, 2464 (4.9%) Black, 3291 (6.5%) Hispanic, 25 (0.1%) Native Hawaiian or Pacific Islander, 30 610 (60.8%) White, 2476 (4.9%) multiracial students, and 834 (1.7%) students of other races or ethnicities. Sex and sexual orientation included 25 672 (51.0%) men and 3078 (6.1%) lesbian, gay, and bisexual (LGB). Childhood family income comprised 31 758 (60.0%) individuals with $75 000 per year or greater, 8160 (16.2%) with $50 000 to $74 999 per year, 6864 (13.6%) with $25 000 to $49 999 per year, and 3612 (7.2%) with less than $25 000 per year. The sample included 7303 (14.5%) AOA members only, 4925 (9.8%) GHHS members only, and 2384 (4.7%) members of both societies. In AOA, American Indian or Alaska Native (OR, 0.49; 95% CI, 0.25-0.96), Asian (OR, 0.49; 95% CI, 0.45-0.53), Black (OR, 0.25; 95% CI, 0.20-0.30), Hispanic (OR, 0.53; 95% CI, 0.47-0.59), multiracial (OR, 0.69; 95% CI, 0.62-0.77), and other race and ethnicity (OR, 0.73; 95% CI, 0.60-0.88) were underrepresented compared with White students; LGB students (OR, 0.75; 95% CI, 0.67-0.83) were underrepresented compared with heterosexual students; and childhood family income $50 000 to $74 999 (OR, 0.81; 95% CI, 0.75-0.86), $25 000 to $49 999 (OR, 0.68; 95% CI, 0.62-0.74), and less than $25 000 (OR, 0.60; 95% CI, 0.53-0.69) were underrepresented compared with greater than or equal to $75 000. In GHHS, Asian students (OR, 0.80; 95% CI, 0.73-0.87) were underrepresented compared with White students, female students (OR, 1.55; 95% CI, 1.45-1.65) were overrepresented compared with male students, LGB students (OR, 1.36; 95% CI, 1.23-1.51) were overrepresented compared with heterosexual students, and students with childhood family income $25 000 to $49 999 (OR, 0.85; 95% CI, 0.78-0.94) and less than $25 000 (OR, 0.75; 95% CI, 0.66-0.86) were underrepresented compared with those with greater than or equal to $75 000. Likelihood of AOA, but not GHHS, membership decreased as number of marginalized identities increased. Conclusions and Relevance:In this cross-sectional study of US medical students, membership disparities were noted in both AOA and GHHS. However, differences in GHHS existed across fewer identities, sometimes favored the marginalized group, and were not cumulative.

BACKGROUND:Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS:Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION/CONCLUSIONS:This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

BACKGROUND:Microaggressions are thought to negatively impact learning and mental health in underrepresented (UR) nursing students. PURPOSE/OBJECTIVE:The purpose of this study was to investigate three hypotheses in a sample of nursing students: (a) whether, compared to White nursing students, UR nursing students experienced higher frequency of microaggressions, (b) whether microaggressions predict lesser satisfaction with nursing training and (c) whether microaggressions are associated with higher depression screening scores. METHODS:A survey during Summer 2020 assessed 862 nursing students (71.8% female, Mean age = 28.8, SD = 9.27, 61.4% White, 20.0% UR) on microaggressions, satisfaction with their nursing program, and depression symptoms. DISCUSSION/CONCLUSIONS:We found that compared to White nursing students, UR nursing students reported significantly greater microaggression frequency (with Black students reporting the highest frequency), lesser nursing training satisfaction, and equivalent potential depression rates. CONCLUSION/CONCLUSIONS:Microaggressions deteriorate indicators of wellbeing, especially in UR nursing students. Strategic action to mitigate microaggressions and promote inclusion is needed.

Importance/UNASSIGNED:The perspectives of gay, lesbian, bisexual (sexual minority [SM]) students about their medical school learning environment and how they relate to burnout is poorly understood. Objective/UNASSIGNED:To understand SM medical students' perceptions of the medical school learning environment and how this is associated with reported burnout. Design, Setting, and Participants/UNASSIGNED:This cross-sectional study included medical students graduating from Association of American Medical Colleges (AAMC)-accredited allopathic US medical schools in 2016 and 2017 and responding to the AAMC Graduation Questionnaire. Data analysis was conducted from June 2021 to March 2022. Exposures/UNASSIGNED:Sexual orientation, based on self-identification, and categorized as bisexual, gay or lesbian, or heterosexual or straight. Main Outcomes and Measures/UNASSIGNED:Primary outcomes included burnout as measured by Oldenburg Burnout Inventory for Medical Students (OLBI-MS; two 24-point scales [range, 0-48], with higher scores indicating greater burnout) and student perceptions of the medical school learning environment (0-5-point scales for emotional climate [range, 0-20] and student-faculty interactions [range, 0-15], with higher scores indicating more positive perceptions). Logistic regression was used to model the association between burnout, SM status, and learning environment while controlling for demographic characteristics. Results/UNASSIGNED:A total of 25 757 respondents (12 527 [48.6%] women; 5347 [20.8%] Asian; 2255 [8.8%] underrepresented in medicine; 15 651 [60.8%] White; 10 726 [41.6%] aged ≤26 years) were included in the analysis: 568 (2.2%) self-identified as bisexual, 854 (3.3%) as gay or lesbian, and 24 335 (94.5%) as heterosexual or straight. Both bisexual students and gay or lesbian students reported less favorable perceptions of their learning environments than heterosexual students (mean [SD] emotional climate score, bisexual students: 8.56 [3.29]; gay or lesbian students: 9.22 [3.33]; heterosexual or straight students: 9.71 [3.20]; P < .001; mean [SD] faculty-student interaction score, bisexual students: 13.46 [3.69]; gay or lesbian students: 14.07 [3.45]; heterosexual or straight students: 14.32 [3.37]; P < .001). Bisexual and gay or lesbian students were more likely to be in the top quartile for burnout scores (bisexual: odds ratio [OR], 1.71; 95% CI, 1.42-2.07; P < .001; gay or lesbian: OR, 1.53; 95% CI, 1.31-1.79; P < .001). This association was attenuated when accounting for student perceptions of the learning environment (bisexual: OR, 1.37; 95% CI, 1.11-1.67; P < .001; gay or lesbian: OR, 1.42; 95% CI, 1.19-1.68; P < .001), with poorer perceptions of the medical school learning environment associated with higher burnout symptoms. Conclusions and Relevance/UNASSIGNED:In this cross-sectional study, SM students had less favorable perceptions of the medical school learning environment compared with heterosexual students. Results suggest the medical school environment may be associated with higher rates of burnout in SM students. Future research should explore interventions to improve the learning environment for SM students.