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MD & DO NEJM: Supporting Trainees from Groups That Are Underrepresented in Medicine

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August 5, 2021
N Engl J Med 2021; 385:487-489
DOI: 10.1056/NEJMp2105270

excerpt:

Now that the 2021 U.S. residency-program match is over, program directors are assessing the success of their diversity-recruitment efforts. In the wake of historic racial unrest and a subsequent recommitment to racial equity by academic medical centers, many program directors embraced holistic reviews of applicants, highlighting talents and skills (e.g., grit) that are frequently overlooked in standard review processes. Residency programs sought to broaden racial and ethnic representation by hosting diversity fairs, revising mission statements to promote inclusive learning environments, adding antiracism statements to their websites, and promoting community service on social media. We are proud that 11 of 22 program directors at our institution, the University of Chicago, opted not to use U.S. Medical Licensing Examination scores for interviewee selection or candidate ranking. In our internal medicine residency program, 84% of applicants belonging to groups that are underrepresented in medicine interviewed with at least one faculty member from an underrepresented group, and 11% interviewed with two such faculty members.
…..
In recruiting diverse intern cohorts, residency programs have made an unspoken promise to provide a safe space for trainees to flourish. Breaking this promise will contribute to medicine’s damaging legacy of discrimination. Keeping this promise will begin healing a wound that must be closed in our generation — and could inspire the rest of the country to begin healing as well.
 
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Billiam95

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Just so I'm getting this straight - PDs should ignore the only objective part of a residency application, or else they will perpetuate racism?
 
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SurfingDoctor

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Chelsea FC

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Just so I'm getting this straight - PDs should ignore the only objective part of a residency application, or else they will perpetuate racism?
Come on, that’s not what this is saying.
 
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Matthew9Thirtyfive

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Come on, that’s not what this is saying.

I mean, it did say that they are proud that PDs ignored step 1 (and I’m guessing also step 2). But I mean the whole purpose of them is to essentially be a pass fail indicator of competency anyway, so I don’t see the problem with that.
 

GoSpursGo

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I mean, it did say that they are proud that PDs ignored step 1 (and I’m guessing also step 2). But I mean the whole purpose of them is to essentially be a pass fail indicator of competency anyway, so I don’t see the problem with that.
Within the context of the paper it does sound like USMLE scores were held in contradistinction to diversity, which I would imagine is a little bit of an exaggeration--there are a lot of reasons that programs probably placed lower weight on USMLE scores than usual related to COVID (difficulty of getting testing dates, having more interview slots since it was all virtual, etc).

But yes I agree that just because USMLE scores have been given weight in the past doesn't mean that it has to continue being given weight. Clearly Step 1 scores are going away soon anyways, so if a program decides that they want to emphasize other factors it's not inherently unfair.
 
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Raryn

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Come on, that’s not what this is saying.
That's *exactly* what this is saying.

We are proud that 11 of 22 program directors at our institution, the University of Chicago, opted not to use U.S. Medical Licensing Examination scores for interviewee selection or candidate ranking
 
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Chelsea FC

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I mean, it did say that they are proud that PDs ignored step 1 (and I’m guessing also step 2). But I mean the whole purpose of them is to essentially be a pass fail indicator of competency anyway, so I don’t see the problem with that.

That's *exactly* what this is saying.
Where did it say they are ignoring Step as a way to stop perpetuating racism like that poster is saying ??
 
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GoSpursGo

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Where did it say they are ignoring Step as a way to stop perpetuating racism like that poster is saying ??
It doesn't have to be explicitly spelled out to understand what they mean. In an article congratulating themselves on how diverse their class is, mentioning how they didn't factor in step 1 score isn't a meaningless non sequitur.
 
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Raryn

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Where did it say they are ignoring Step as a way to stop perpetuating racism like that poster is saying ??
The title of the piece is "Keeping Our Promise — Supporting Trainees from Groups That Are Underrepresented in Medicine" and they explicitly bring up not considering Step 1 in that context.
 
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Matthew9Thirtyfive

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Where did it say they are ignoring Step as a way to stop perpetuating racism like that poster is saying ??
It is not explicitly said, but that is like the whole point of it. Like I said, it outright states that programs who are ignoring objective measures like step scores in favor of diversity should be applauded. I agree with @GoSpursGo in that it’s a bit of an exaggeration probably, as I’m sure they took passing or failing step into consideration. If they didn’t, then they are definitely going way too far in the opposite direction.
 
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I didnt think the article would be controversial. I posted it for the encouragement of URM medical students. But alas….here we are. Comments on the original article online by subscribers are also sadly misguided.

Some seem to believe that matching into a residency program has always been based principally on USMLE Step 1 scores, aka “the only objective part”. Indeed many have watched in dismay for these past 20 years how studying for the Step 1 has become insanely obsessive. This at the exclusion of learning how to be a physician when juxtaposed to skipping lectures, shunning relationships with faculty (both MD and PhD types), not buying textbooks, and memorizing First Aid, Pathoma and other online extracurricular resources.

Abandoning the USMLE Step 1 score cutoff rubric was long overdue. As for how programs will now perform matches, this isnt a terribly new phenomenon. Historically the match was always perceived as a dubious clearinghouse mechanism, at times rigged by hospitals at the expense of medical students. So the most recent formulation of matching as stated in the NEJM article, especially for URM, is a very positive development. Well done.

See:

Roth AE. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909

 
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aldol16

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Disregarding Step 1 or not is a moot topic after this year. What's more important is how systems should be instituted afterwards to make sure that we aren't perpetuating racism in the system and selection process. While the article is well-intentioned, I found it focused way too much on race and not enough on other socioeconomic parameters. Race is only one factor. I would argue that patients would likely identify even more closely with a physician who shares (or at least shared) their socioeconomic status. It's more powerful to hear from someone who has had a similar lived experience as you than someone who shares your race but otherwise has not had the same lived experience. Obviously these are correlated. But the point is, there are many dimensions of "underrepresentation" that have to be accounted for.
 
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GoSpursGo

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Disregarding Step 1 or not is a moot topic after this year. What's more important is how systems should be instituted afterwards to make sure that we aren't perpetuating racism in the system and selection process. While the article is well-intentioned, I found it focused way too much on race and not enough on other socioeconomic parameters. Race is only one factor. I would argue that patients would likely identify even more closely with a physician who shares (or at least shared) their socioeconomic status. It's more powerful to hear from someone who has had a similar lived experience as you than someone who shares your race but otherwise has not had the same lived experience. Obviously these are correlated. But the point is, there are many dimensions of "underrepresentation" that have to be accounted for.
Your point is valid, but that's not what this article focused on. Someone else should write the article you're describing :) Mind you, the article would be much much harder to write, because I don't think the socioeconomic background of residency applicants would be readily available. But in any event, just because you can't write a perfect article (and this was a "perspective" paper for goodness sake) doesn't mean you shouldn't add what you do have to the literature.
 
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aldol16

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Your point is valid, but that's not what this article focused on. Someone else should write the article you're describing :) Mind you, the article would be much much harder to write, because I don't think the socioeconomic background of residency applicants would be readily available. But in any event, just because you can't write a perfect article (and this was a "perspective" paper for goodness sake) doesn't mean you shouldn't add what you do have to the literature.
Yeah and I would go so far as to say just because something is really difficult to measure doesn't mean that it's any less important. In some instances, it may even be more important than the readily available outcomes. To draw a comparison, too often in clinical medicine we see studies that measure mortality as the primary (and in many cases, the only) endpoint. Mortality is relatively easy to measure. Harder to measure is a patient's quality of life. I would argue that for many patients, quality of life is almost as important as, if not more important than, mortality. But it's hard to measure objectively so it's often brushed under the rug.
 

SurfingDoctor

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I for one am disappointed they are getting rid of scoring on step 1. Certainly failing is failing, but even marginal step 1 test takers tend to be marginal trainees in my experience. Its not always true, but its more often true than not.
 
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