Experiences with Racism Among Asian American Medical Students
IMPORTANCE/UNASSIGNED: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/UNASSIGNED:To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED: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/UNASSIGNED:The medical school experiences of Asian American medical students. RESULTS/UNASSIGNED: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/UNASSIGNED: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.
Ensuring Fairness in Medical Education Assessment
The Long Shadow: A Historical Perspective on Racism in Medical Education
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.
Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity with Sustained and Cultivated Careers in Surgery
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.
Transition From Mentored to Independent NIH Funding by Gender and Department
Temporal Trends in Childhood Household Income Among Applicants and Matriculants to Medical School and the Likelihood of Acceptance by Income, 2014-2019
Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study
Background: Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. Objective: We report the incidence and indications for rescue surgical airways using a multicenter observational registry. Methods: We performed a retrospective analysis of rescue surgical airways in subjects â‰¥14 years of age. We describe patient, clinician, airway management, and outcome variables. Results: Of 19,071 subjects in NEAR, 17,720 (92.9%) were â‰¥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). Conclusion: Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.
Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study
BACKGROUND:Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE:We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS:We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS:Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION:Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.
Political Priorities, Voting, and Political Action Committee Engagement of Emergency Medicine Trainees: A National Survey
INTRODUCTION:Medicine is increasingly influenced by politics, but physicians have historically had lower voter turnout than the general public. Turnout is even lower for younger voters. Little is known about the political interests, voting activity, or political action committee (PAC) involvement of emergency physicians in training. We evaluated EM trainees' political priorities, use of and barriers to voting, and engagement with an emergency medicine (EM) PAC. METHODS:Resident/medical student Emergency Medicine Residents' Association members were emailed a survey between October-November 2018. Questions involved political priorities, perspective on single-payer healthcare, voting knowledge/behavior, and EM PACs participation. We analyzed data using descriptive statistics. RESULTS:Survey participants included 1,241 fully responding medical students and residents, with a calculated response rate of 20%. The top three healthcare priorities were as follows: 1) high cost of healthcare/price transparency; 2) decreasing the number of uninsured; and 3) quality of health insurance. The top EM-specific issue was ED crowding and boarding. Most trainees (70%) were supportive of single-payer healthcare: "somewhat favor" (36%) and "strongly favor" (34%). Trainees had high rates of voting in presidential elections (89%) but less frequent use of other voting options: 54% absentee ballots; 56% voting in state primary races; and 38% early voting. Over half (66%) missed voting in prior elections, with work cited as the most frequent (70%) barrier. While overall, half of respondents (62%) reported awareness of EM PACs, only 4% of respondents had contributed. CONCLUSION:The high cost of healthcare was the top concern among EM trainees. Survey respondents had a high level of knowledge of absentee and early voting but less frequently used these options. Encouragement of early and absentee voting can improve voter turnout of EM trainees. Concerning EM PACs, there is significant room for membership growth. With improved knowledge of the political priorities of EM trainees, physician organizations and PACs can better engage future physicians.
Perspectives on National Institutes of Health Funding Requirements for Racial and Ethnic Diversity Among Medical Scientist Training Program Leadership
IMPORTANCE:Since 1964, the National Institutes of Health (NIH) has funded the Medical Scientist Training Program (MSTP) MD-PhD program at medical schools across the US to support training physician-scientists. Recent studies have suggested that MSTPs have consistently matriculated more students from racial and ethnic backgrounds historically underrepresented in science than MD-PhD programs without NIH funding; however, the underlying basis for the increased diversity seen in NIH-funded MSTPs is poorly understood. OBJECTIVE:To investigate how administrators and faculty perceive the impact of MSTP status on MD-PhD program matriculant racial and ethnic diversity. DESIGN, SETTING, AND PARTICIPANTS:This qualitative study used a positive deviance approach to identify 9 high-performing and 3 low-performing MSTPs based on the percentage of students underrepresented in science who matriculated into the program between 2014 and 2018. This study, a subanalysis of a larger study to understand recruitment of students underrepresented in science at MSTPs, focused on in-depth qualitative interviews, conducted from October 26, 2020, to August 31, 2022, of 69 members of MSTP leadership, including program directors, associate and assistant program directors, and program administrators. MAIN OUTCOMES AND MEASURES:The association of NIH funding with institutional priorities, programs, and practices related to MD-PhD program matriculant racial and ethnic diversity. RESULTS:The study included 69 participants (mean [SD] age, 53  years; 38 women [55%]; 13 African American or Black participants [19%], 6 Asian participants [9%], 12 Hispanic participants [17%], and 36 non-Hispanic White participants [52%]). A total of 51 participants (74%) were in administrative roles, and 18 (26%) were faculty involved in recruitment. Five themes emerged from the data: (1) by tying MSTP funding to diversity efforts, the NIH created a sense of urgency among MSTP leadership to bolster matriculant diversity; (2) MD-PhD program leadership leveraged the changes to MSTP grant review to secure new institutional investments to promote recruitment of students underrepresented in science; (3) MSTPs increasingly adopted holistic review to evaluate applicants to meet NIH funding requirements; (4) MSTP leadership began to systematically assess the effectiveness of their diversity initiatives and proactively identify opportunities to enhance matriculant diversity; and (5) although all MSTPs were required to respond to NIH criteria, changes made by low-performing programs generally lacked the robustness demonstrated by high-performing programs. CONCLUSIONS AND RELEVANCE:This study suggests that NIH funding requirements may be a powerful incentive to promote diversity and positively affect representation of students underrepresented in science in the biomedical scientific workforce.