Protecting underrepresented students and residents during COVID-19

The current pandemic is impacting all segments of society—but not equally—and it has created significant disruptions in medical education. Even prior to the pandemic, national data suggested medical education was already losing ground with respect to racial and ethnic parity.¹

Recent weeks have brought additional stressors to the fore as our society continues to  grapple with structural racism. The medical education community must remain vigilant for potential inequities in educational outcomes across the medical education continuum. Diversity efforts are particularly vulnerable during times of disruption, hence institutions must heighten their commitment of attention and resources.

It is the responsibility of the AMA to advocate for medical students, to act to reverse the historic active exclusion of racially marginalized groups (specifically, Blacks, Latinx and Native Americans) from the practice of medicine and to drive advancement of multiple dimensions of diversity in the medical profession. Broader initiatives to foster long-term change in medicine and address inequities in the entire United States educational system are imperative and are underway.

Current disruptions related to COVID-19, however, may amplify underlying inequities in our educational system, similar to the pandemic’s role in exacerbating health inequities. Recent societal unrest in response to ongoing public racist acts of violence further compounds immediate concerns. Detailed examples of pressing risks for inequity in educational outcomes are provided here.

Concerns span the continuum of pre-medical education, transition to medical school, performance during medical school, residency selection and performance in graduate medical education. Although this highlights immediate risks posed by current circumstances, these recommendations should be applied as long-term interventions.

Colleges, medical schools and residency programs should:

• Increase attention to structural determinants of academic success and provide a clear process by which students can report challenges and seek assistance.
• Engage students, residents and faculty from underrepresented backgrounds (particularly racial and socioeconomic) in the process of planning adjustments to curriculum, assessment and application processes in order to better consider the diverse circumstances of students.
• Amplify efforts to create inclusive learning and working environments across the continuum of pre-medical education, medical school, graduate medical education and practice.
• Heighten monitoring of learner well-being at all levels of medical education and minimize barriers to mental health care.
• Implement a systems approach to promoting well-being that serves to complement the resilience of individuals. Organizational-level efforts should be undertaken to provide:
  • Consistent and inclusive communication.
  • Clarity regarding changes in curriculum, performance expectations or administrative processes.
  • Allyship to address microaggressions in clinical and learning environments.
  • Responsiveness to student and resident concerns.
  • Processes for addressing student and resident grievances.
• Adjust medical school admissions and residency selection processes to:
  • Mitigate bias (e.g. review of applications blinded to academic metrics bias training for admissions committees and interviewers).
  • Apply novel screening practices (e.g. situational judgment tests).
  • Incorporate more holistic, inclusive selection criteria (e.g. distance traveled score).
  • Monitor outcomes for potential bias related to any newly implemented or modified approaches in admissions and selection.
• Improve communication in medical school admissions and residency selection processes by:
  • Implementing robust outreach to students from disadvantaged and underrepresented backgrounds.
  • Developing targeted platforms to foster bilateral exchange of information between applicants and medical schools or residency programs respectively.
  • Reducing complexity and improving transparency in application and selection processes.
  • Minimizing the disparities in candidates’ access to coaching in selection processes, such as by providing tips for success at the level of the receiving medical school or graduate medical education (GME) program.
• Increase commitment to, and investment in, pathway and retention programs and other initiatives that intentionally promote equity, diversity and inclusion.

Similar themes apply across the continuum of pre-medical education, transition to medical school, performance during medical school, residency selection and performance in GME.

• The shift to virtual platforms of educational delivery has revealed inequities that may further limit the academic achievement of students from under-resourced urban and rural communities, such as in:
  • Access to technology, including internet access and appropriate devices.
  • Home circumstances, including dedicated space and a quiet environment in which to work.
• Students are losing enrichment activities that carry particular importance to candidates who are from backgrounds underrepresented in medicine or who have perceived weaknesses in other aspects of their portfolios. Activities such as research, shadowing, global health experiences and clinical electives serve to instill confidence in pursuing a medical career, support exploration among medical disciplines, spur mentoring, and provide opportunities for distinction that contribute to successful advancement.
• Geographic inconsistency in administration of Medical Colleges Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step examinations has induced some students to consider travel for testing, which will amplify existing disparity in access and in completeness of application portfolios.
• Geographic variations in COVID-19 impact and response—such as physical distancing requirements, testing availability, and availability of personal protective equipment—will create inconsistency in recovery of medical student clinical activities among schools and may disproportionately impact under-resourced schools.
• Limited clinical activities may reduce medical students’ access to advocacy in the residency application process (as in the form of letters of recommendation or other communication) which is particularly valuable to disadvantaged candidates.
• Limitations on medical student participation in away rotations, of particular importance for students to demonstrate their abilities to prospective GME programs and to assess the culture of those programs, may disproportionately disadvantage candidates who are underrepresented or who have perceived weaknesses in other aspects of their portfolios.
• The shift to virtual interviews for both medical school and residency selection may have disproportionately negative impacts on students from underrepresented groups or under-resourced communities, due to limitations in technology and appropriate dedicated space as well as less time and personal presence to overcome bias.
• Because people of color are experiencing COVID-19 disproportionately, there may be a corresponding emotional toll on students and residents who lose family and friends to the disease.
• The families of students and residents of color or those who are from lower socioeconomic status may be experiencing greater economic burden from COVID-19, perhaps due to losing employment or increased costs of essential goods. Students may prioritize the need to help support their families over school-related obligations.
• The current environment of racial and societal unrest may have disproportionately negative impacts on the well-being of students and residents from minority communities, impairing their ability to succeed in course work and to navigate application processes.
• Pathway and recruitment programs may suffer from disrupted opportunities to interact with students; and financial strain on many academic centers may result in decreased support to such programs, both in financial resources and in the engagement of participating faculty.

ACGME News: Increasing Graduate Medical Education Diversity and Inclusion, McDade

AAMC: Holistic Review in Medical School Admissions

¹Talamantes, et al. Closing the Gap - Making Medical School Admissions More Equitable. NEJM 2019. (As medical school enrollment doubled over the past two decades, the percentage of entering under-represented students actually fell by 16%)