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Letters of Reference in the Current Era

Gottlieb, Michael; Boatright, Dowin; Landry, Adaira
Letters of reference (LORs) are a common component of the application process for residency training programs. With the United States Medical Licensing Examination Step 1 transitioning to pass/fail grading and with the increasing use of holistic review, the potential role of LORs is rising in importance. Among some key benefits are the ability to provide a broader and more holistic view of applicants, which can include highlighting elements of experiences or skills that could be missed in their application, as well as providing a third-party assessment of the applicant external to their rotation experiences. However, LORs also face issues, including variation in quality, challenges with comparability, and risk of bias. In this article, the authors discuss the unique benefits, limitations, and best practice recommendations for LORs in academic medicine. The authors also discuss future directions, including the role of artificial intelligence, unblinded, and co-created LORs.
PMID: 38781284
ISSN: 1938-808x
CID: 5654942

Outcomes of the Main Residency Match for Applicants With Disability

Nguyen, Mytien; Meeks, Lisa M; Sheets, Zoie C; Betchkal, Rylee; Pereira-Lima, Karina; Moreland, Christopher J; Boatright, Dowin H
PMID: 38630504
ISSN: 1538-3598
CID: 5655862

Leave of Absence and Medical Student Placement Into Graduate Medical Education by Race and Ethnicity

Nguyen, Mytien; Mason, Hyacinth R C; Russell, Regina; Fancher, Tonya; Chaudhry, Sarwat I; Desai, Mayur M; Boatright, Dowin
PMID: 38619837
ISSN: 1538-3598
CID: 5655792

Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity with Sustained and Cultivated Careers in Surgery

Nguyen, Mytien; Gonzalez, Luis; Stain, Steven C; Dardik, Alan; Chaudhry, Sarwat I; Desai, Mayur M; Boatright, Dowin; Butler, Paris D
OBJECTIVE:Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school. METHODS:This retrospective cohort study examines U.S. medical students who matriculated in academic years 2014-2015 and 2015-2016. Data was provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined two outcomes: 1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery, and 2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation. RESULTS:Among the 5,074 students who reported interest in surgery at matriculation, 2,108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery (aRR: 0.92 (0.85-0.98)), while Asian (aRR: 0.82, 95%CI: 0.74-0.91), Hispanic (aRR: 0.70, 95%CI: 0.59-0.83), and low-income (aRR: 0.85, 95%CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a non-surgical specialty, 1,869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with URiM female students reporting the lowest rates. CONCLUSION AND RELEVANCE/CONCLUSIONS:This study demonstrates significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for female, URiM, and low-income students is essential to diversify the surgical workforce.
PMID: 37470162
ISSN: 1528-1140
CID: 5535922

Development of a Tool to Measure Student Perceptions of Equity and Inclusion in Medical Schools

Boatright, Dowin; Nguyen, Mytien; Hill, Katherine; Berg, David; Castillo-Page, Laura; Anderson, Nientara; Agbelese, Victoria; Venkataraman, Shruthi; Saha, Somnath; Schoenbaum, Stephen C; Richards, Regina; Jordan, Ayana; Asabor, Emmanuella; White, Marney A
IMPORTANCE/UNASSIGNED:Creating an inclusive and equitable learning environment is a national priority. Nevertheless, data reflecting medical students' perception of the climate of equity and inclusion are limited. OBJECTIVE/UNASSIGNED:To develop and validate an instrument to measure students' perceptions of the climate of equity and inclusion in medical school using data collected annually by the Association of American Medical Colleges (AAMC). DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:The Promoting Diversity, Group Inclusion, and Equity tool was developed in 3 stages. A Delphi panel of 9 members identified survey items from preexisting AAMC data sources. Exploratory and confirmatory factor analysis was performed on student responses to AAMC surveys to construct the tool, which underwent rigorous psychometric validation. Participants were undergraduate medical students at Liaison Committee on Medical Education-accredited medical schools in the US who completed the 2015 to 2019 AAMC Year 2 Questionnaire (Y2Q), the administrations of 2016 to 2020 AAMC Graduation Questionnaire (GQ), or both. Data were analyzed from August 2020 to November 2023. EXPOSURES/UNASSIGNED:Student race and ethnicity, sex, sexual orientation, and socioeconomic status. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Development and psychometric validation of the tool, including construct validity, internal consistency, and criterion validity. RESULTS/UNASSIGNED:Delphi panel members identified 146 survey items from the Y2Q and GQ reflecting students' perception of the climate of equity and inclusion, and responses to these survey items were obtained from 54 906 students for the Y2Q cohort (median [IQR] age, 24 [23-26] years; 29 208 [52.75%] were female, 11 389 [20.57%] were Asian, 4089 [7.39%] were multiracial, and 33 373 [60.28%] were White) and 61 998 for the GQ cohort (median [IQR] age, 27 [26-28] years; 30 793 [49.67%] were female, 13 049 [21.05%] were Asian, 4136 [6.67%] were multiracial, and 38 215 [61.64%] were White). Exploratory and confirmatory factor analyses of student responses identified 8 factors for the Y2Q model (faculty role modeling; student empowerment; student fellowship; cultural humility; faculty support for students; fostering a collaborative and safe environment; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation) and 5 factors for the GQ model (faculty role modeling; student empowerment; faculty support for students; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation). Confirmatory factor analysis indicated acceptable model fit (root mean square error of approximation of 0.05 [Y2Q] and 0.06 [GQ] and comparative fit indices of 0.95 [Y2Q] and 0.94 [GQ]). Cronbach α for individual factors demonstrated internal consistency ranging from 0.69 to 0.92 (Y2Q) and 0.76 to 0.95 (GQ). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found that the new tool is a reliable and psychometrically valid measure of medical students' perceptions of equity and inclusion in the learning environment.
PMID: 38381434
ISSN: 2574-3805
CID: 5634312

Challenges Facing First-Generation College Graduates in Medical School: A Qualitative Analysis

Havemann, Catherine; Mason, Hyacinth R C; Russell, Regina G; Casillas, Alejandra; Nguyen, Mytien; Boatright, Dowin; Webber, Alexis; Parilla, Jon Andre; Gallegos, Abraham; Wyatt, Tasha R
IMPORTANCE/UNASSIGNED:First-generation (FG) medical students remain underrepresented in medicine despite ongoing national efforts to increase diversity; understanding the challenges faced by this student population is essential to building holistic policies, practices, and learning environments that promote professional actualization. Although FG students have been extensively studied in the undergraduate literature, there is little research investigating how FG students experience medical education or opportunities for educators to intervene. OBJECTIVE/UNASSIGNED:To explore challenges that FG students experience in undergraduate medical education and identify opportunities to improve foundational FG support. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study was conducted using an online platform with 37 FG students enrolled in 27 US medical schools. An interprofessional team of medical educators and trainees conducted semistructured interviews from November 2021 through April 2022. Participants were recruited using a medical student listserv. Data were analyzed from April to November 2022. MAIN OUTCOMES AND MEASURES/UNASSIGNED:After conducting a preliminary analysis using open coding, a codebook was created and used in a thematic analysis; the codebook used a combination of deductive and inductive coding. RESULTS/UNASSIGNED:Among the 37 students recruited for this study, 21 (56.8%) were female; 23 (62.2%) were in the clinical phase of training; 1 (2.7%) was American Indian or Alaska Native, 7 (18.9%) were Hispanic, Latino, or of Spanish origin, 8 (21.6%) were non-Hispanic Asian or Asian American, 9 (24.3%) were non-Hispanic Black or African American, and 23 (32.4%) were non-Hispanic White; mean (SD) age was 27.3 (2.8) years. Participants described 4 major themes: (1) isolation and exclusion related to being a newcomer to medicine; (2) difficulty with access to basic resources (eg, food, rent, transportation) as well as educational (eg, books); (3) overall lack of faculty or institutional support to address these challenges; and (4) a sense of needing to rely on grit and resilience to survive. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Although grit and resilience are desirable traits, results of this study suggest that FG medical students face increased adversity with inadequate institutional support, which forces them to excessively rely on grit and resilience as survival (rather than educational) strategies. By applying the holistic model often used in admissions to the postmatriculation educational process, targeted and flexible initiatives can be created for FG students so that all students, regardless of background, can achieve robust professional actualization.
PMID: 38091039
ISSN: 2574-3805
CID: 5589292

Promising Practices in US Sponsoring Institutions to Advance Diversity, Equity, and Inclusion in Graduate Medical Education

Sanchez, Stephany; Westervelt, Marjorie; Boatright, Dowin; Fancher, Tonya; London, Maya; Concepcion, Arra Jane; Manriquez, Jose A Negrete; McDade, William; Gonzalo, Jed D
PMID: 38045934
ISSN: 1949-8357
CID: 5590562

Experiences with Racism Among Asian American Medical Students

Yang, David H; Justen, Marissa; Lee, Dana; Kim, Heeryoung; Boatright, Dowin; Desai, Miraj; Tiyyagura, Gunjan
IMPORTANCE:Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students. OBJECTIVE:To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment. DESIGN, SETTING, AND PARTICIPANTS:This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years. MAIN OUTCOMES AND MEASURES:The medical school experiences of Asian American medical students. RESULTS:Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future. CONCLUSIONS AND RELEVANCE:In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.
PMID: 37695582
ISSN: 2574-3805
CID: 5593702

The Long Shadow: A Historical Perspective on Racism in Medical Education

Anderson, Nientara; Nguyen, Mytien; Marcotte, Kayla; Ramos, Marco; Gruppen, Larry D; Boatright, Dowin
To dismantle racism in U.S. medical education, people must understand how the history of Christian Europe, Enlightenment-era racial science, colonization, slavery, and racism shaped modern American medicine. Beginning with the coalescence of Christian European identity and empire, the authors trace European racial reasoning through the racial science of the Enlightenment into the White supremacist and anti-Black ideology behind Europe's global system of racialized colonization and enslavement. The authors then follow this racist ideology as it becomes an organizing principle of Euro-American medicine and examine how it manifests in medical education in the United States today. Within this historical context, the authors expose the histories of violence underlying contemporary terms such as implicit bias and microaggressions. Through this history, they also gain a deeper appreciation of why racism is so prevalent in medical education and how it affects admissions, assessments, faculty and trainee diversity, retention, racial climate, and the physical environment. The authors then recommend 6 historically informed steps for confronting racism in medical education: (1) incorporate the history of racism into medical education and unmask institutional histories of racism, (2) create centralized reporting mechanisms and implement systematic reviews of bias in educational and clinical activities, (3) adopt mastery-based assessment in medical education, (4) embrace holistic review and expand its possibilities in admissions, (5) increase faculty diversity by using holistic review principles in hiring and promotions, and (6) leverage accreditation to combat bias in medical education. These strategies will help academic medicine begin to acknowledge the harms propagated throughout the history of racism in medicine and start taking meaningful steps to address them. Although the authors have focused on racism in this paper, they recognize there are many forms of bias that impact medical education and intersect with racism, each with its particular history, that deserve their own telling and redress.
PMID: 37071703
ISSN: 1938-808x
CID: 5466092

Ensuring Fairness in Medical Education Assessment

Boatright, Dowin; Edje, Louito; Gruppen, Larry D.; Hauer, Karen E.; Humphrey, Holly J.; Marcotte, Kayla
ISSN: 1040-2446
CID: 5567832