First aid: the immediate assistance given to a person with an injury or illness. Ironically, for medical school students, it is their most coveted book used to pass a licensing examination. For some students who are underrepresented in medicine (URiM), this licensing examination will determine their fate. Physicians are considered URiM if, as defined by the Association of American Medical Colleges, they represent “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”1  Studies have shown that racial and ethnic minority patients, who historically suffer from greater health care disparities, are more likely to seek care from physicians URiM.2,3  Physicians URiM may feel obligated to cater to their racial and ethnic populations and choose a specialty or practice location based on the needs of these groups. In fact, compared to white physicians, physicians URiM are more likely to practice in underserved areas, which typically comprise a high population of racial and ethnic minorities.4  Because of the lack of numbers and the increased demand placed on physicians from populations URiM, there is more need for these physicians than can be met.3 

The medical workforce does not reflect the diversity in the general population.4,5  Each year, the residency match allots medical departments an opportunity to further diversify their physician workforce; however, navigating the recruitment of persons URiM can be difficult in a setting with an inadequate pipeline from medical school into residency.

On February 12, 2020, the National Board of Medical Examiners (NBME) announced that the United States Medical Licensing Examination (USMLE) Step 1 will transition to being reported as pass/fail rather than a 3-digit score. The long-term implications of this change on medical education and residency selection have yet to be determined but could be advantageous to both residency programs and those URiM.

According to the NBME, the purpose of the USMLE is to provide an objective measure of the minimal level of knowledge and competency required to obtain medical licensure. However, the USMLE Step 1 examination has been reported as the most important factor in ranking applicants by program directors.6  Performance on multiple-choice examinations, such as the USMLE Step 1, have been correlated with future performance on multiple-choice examinations, which is not the ultimate goal of our medical training.79  Furthermore, non-white examinees historically score lower on the USMLE Step 1 than white test takers. Therefore, applicants URiM represent a disproportionately smaller percentage of applicants selected for interview, and are consistently the least represented among competitive specialties.8,10  Standardized examinations like the USMLE Step 1 place those URiM at a disadvantage when applying to residency.11  Given this inequity, it seems fitting that this examination will now be reported as pass/fail rather than a numeric score.

As the USMLE Step 2 examination will continue to be reported with a 3-digit score, there is concern that program directors will now place more importance on this score as it was already ranked the fourth most important factor in selecting applicants to interview.6  While it provides objective measures for comparison, neither USMLE Step 1 nor Step 2 account for other qualities equally as important to being a well-rounded physician such as empathy, research capabilities, communication skills, leadership, teamwork, or diverse perspectives. Although there is recognition in the importance of these other qualities outside of board scores, they appear less prioritized among program directors. Per the NRMP Program Director Survey 2018, leadership qualities were ranked 13th, volunteer and extracurricular experiences were ranked 19th, and fluency in languages spoken by your patient population was ranked 31st out of 33 criteria.6  This mindset was further demonstrated among a review of orthopedic candidates, which saw that white applicants were more likely to get accepted despite URiM applicants having more publications and volunteer experiences.12  Until a shift in mindset is seen among program leadership, internal reviews for potential unconscious biases in the residency selection process are performed, and changes are enacted to review applicants holistically, we will continue to encounter problems with bias in the residency selection process and therefore an inequitable workforce.

Diversity initiatives that can be readily implemented by residency programs for the 2020–2021 recruitment season are discussed here and delineated in the Box. Residency programs can create a diversity task force designed to recruit applicants URiM. Working with local undergraduate institutions and medical schools to establish mentorship and provide opportunities for students URiM is crucial to helping supply the pipeline. One way to accomplish this is by reaching out to minority organizations or starting specialty interest groups in order to develop longitudinal relationships and communication with students URiM. In addition, updating the residency program website to reflect a commitment to a diverse and inclusive culture is a simple first step that can capture interest of applicants who are URiM.

Box Diversity Initiatives
Before Interview Season
  • Establish a diversity committee

    • Add faculty URiM to residency selection committee

  • Offer funded/scholarship-based elective rotation for students URiM

  • Update program website

    • Add diversity information

    • Revise mission statement to include commitment to diversity

  • Establish a relationship with college and medical students who are URiM

    • Develop mentoring/shadowing experiences for college and medical students URiM

    • Engage in recruitment activities at institutions and national meetings targeted toward college and medical students URiM

    • Recruitment and engagement of college students URiM is crucial for building numbers of medical students URiM

When Reviewing Residency Applications
  • Holistic review of applicants emphasizing:

    • Commitment to underserved

    • Substantive leadership roles

    • Fluency in more than one language

    • Representation of city's diverse population

    • Socioeconomic hardships

    • Decrease focus/thresholds on traditional metrics (board scores, grades, number of authored publications)

On Interview Day
  • Establish designated interview days for students URiM

  • Standardize interview questions

  • Highlight program's commitment to diversity

    • Increase involvement of faculty/trainees URiM

    • Offer reception/meeting with faculty/trainees URiM

After Interview Day
  • Funded second-look event for residency candidates URiM

  • Targeted outreach to candidates URiM

  • Prerank nights:

    • Additional time to discuss applicants URiM

  • Intentionally rank talented applicants URiM highly

The recruitment and selection of applicants URiM is vital and complicated, as it not only involves outreach, but also a thorough and systematic review of applications. Two of the ACGME core competencies are interpersonal and communication skills and professionalism. A comprehensive review of a candidate's online application can provide some insight into a future physician's potential in developing these competencies.13  Implementing holistic review is being intentional about how an applicant can contribute to your institutional mission. Furthermore, ensuring that screeners and interviewers have undergone unconscious bias training and emphasizing diversity, volunteerism, work experience, socioeconomic barriers overcome, and languages spoken when selecting interview candidates or ranking can help to mitigate biases.

Decreased reliance by residency programs on USMLE Step 1 as a primary screening tool will help move toward leveling the playing field and emphasize a holistic review of a candidate's application. Students in turn may feel that their application is now more appealing to a variety of residency programs or specialties. More students from URiM populations may feel empowered to apply to specialties they may have abandoned because they believed their application would not be considered during initial screening processes due to their USMLE Step 1 Score.12 

In conclusion, we recognize that altering the application review and selection process will not come easily, as it involves changes that need to be initiated and implemented by program and hospital leadership. Ultimately, this will require more faculty involvement, especially those URiM who might already be pulled in multiple directions, and greater incentives from hospital systems to recruit and retain clinicians URiM. Notably, several residency programs that implemented diversity initiatives such as a holistic review (Box) have reported improvements in the number of residency applicants, interviewees, and matriculates from populations URiM.1420  These initiatives can serve as a framework for other programs to implement in their interview process. We understand implementing these initiatives will be challenging, given the continuously increasing number of residency applications submitted each year and the increased demands of a holistic review process. However, if we are to continue training physicians who view patients beyond lab values and disease processes, it is imperative that the resident selection process allows for students to tell their story before being screened out based on a numerical value that was never meant to be used for that purpose. It seems the USMLE Step 1 becoming pass/fail is the “first aid” step in this direction.

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Author notes

Joshua M. Romero, MD, is a Resident Physician, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester; Claudia I. Martinez, MD, is a Resident Physician, Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston; Ashley N. Sanchez, MD, is a Resident Physician, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston; Joel E. Frontera, MD, is Associate Professor, Vice Chair of Education, and Program Director, Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston; Miguel X. Escalon, MD, is Vice Chair, Associate Professor, and Program Director, Department of Rehabilitation and Human Performance, Mount Sinai; and Monica Verduzco-Gutierrez, MD, is Professor and Chair, Department of Rehabilitation Medicine, Long School of Medicine, University of Texas Health Science Center.