Looking Beyond the Numbers: Increasing Diversity and Inclusion Through Holistic Review in General Surgery Recruitment

Objective

The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program.

Design

A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups.

Setting

General Surgery residency program at a tertiary, academic center.

Participants

Medical students applying for and matriculated to categorical positions.

Results

After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior “traditional” approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09).

Conclusions

Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process.

Introduction

There is a paucity of physicians who identify as underrepresented in medicine (UIM) despite a growing minority population in the United States.1, 2, 3, 4 This is especially important to note because UIM physicians are more likely to care for UIM patients, who historically have less access to healthcare and poorer health outcomes than their white counterparts.⁵ Similarly, despite almost equal representation in medical schools, fewer women progress through the ranks of academia and surgical leadership.6, 7, 8, 9 In order to help close the representation gap, various governing bodies in healthcare, schools, and institutions have emphasized a commitment to diversity and inclusion.^10,11

Diversity and inclusion in healthcare are means to achieving institutional excellence.¹² A diverse workforce provides a broad range of experiences and perspectives that can help solve difficult problems more efficiently and broaden the views if its constituents.¹³ Moreover, UIM patients tend to view the quality of their care more favorably if they are taken care of by a physician with similar racial or ethnic background.¹⁴ These interactions can result in continued access to care for a population that otherwise would not seek care for fear of cultural incompetence from a racial- or ethnic-discordant physician.¹⁴

The National Academy of Medicine (formerly the Institute of Medicine) recommends that the number of minority health professionals in the United States be increased to be more reflective of the national demographics.¹⁵ Medical schools are required by the Liaison Committee on Medical Education to promote diversity and inclusion within their student body and faculty. The expectation is that increasing diversity within these institutions will result in the development of physicians who are culturally aware and able to work on improving access to healthcare and eliminating healthcare disparities.16, 17, 18

In order to increase the diversity of their matriculants, many medical schools have implemented holistic review of student applications throughout their recruitment processes.¹⁹ The Association of American Medical Colleges (AAMC) defines holistic review as a “flexible, individualized way of assessing an applicant's capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and future physician.”²⁰ The goal of such a review would be to highlight well-rounded, enlightened doctors-in-training who would be equipped to deliver comprehensive and culturally sensitive care to numerous communities as physicians.

In 2014, the Urban Universities for HEALTH reported results of a national survey of health professions schools in the United States, in which 91% of medical schools reported using holistic review in student admissions.²¹ Schools with many elements of a holistic review process demonstrated substantial increases in diversity. Despite proven success, this practice is not well documented or implemented in general surgery resident selection. The existing, “traditional” approach to resident selection in many general surgery residency programs relies heavily on objective metrics such as United States Medical Licensing Examination (USMLE) scores, clerkship grades, and class ranking.²² Our study aims to examine the effects of a holistic application review process on the recruitment of women and UIM students in our general surgery residency. We hypothesize that a holistic approach would result in the successful recruitment of more women and UIM applicants.