Medical students identifying as lesbian, gay, bisexual, transgender, queer/questioning, and other sexual/gender minorities (LGBTQ+) face unique challenges and discrimination during medical training and when applying to medical residency.1–6 The current evidence base is full of examples, and through fear of possible discrimination, medical students and physicians who identify as LGBTQ+ may choose to conceal their identities.2,4,6 Research suggests that LGBTQ-identified medical students are more likely to experience and report mistreatment, and more likely than straight-identified peers to experience burnout.3,5 A recent small study reported that over 50% of surveyed trans and/or nonbinary residents felt unsafe sharing their gender identities during residency interviews, and over 40% were misgendered during the interview process.4 As has been well described, the 2020–2021 residency interview season in the United States was conducted virtually due to the COVID-19 pandemic.7 This article will explore how the recent US virtual residency interview season may have both mitigated and exacerbated challenges and discriminatory practices facing LGBTQ+ trainees, and will propose best practices for recruiting these trainees.
Increased Equity
Virtual interviews might enable increased equity for LGBTQ+ applicants with regard to minoritized sexual orientation and gender identity. As applicants in the 2020–2021 virtual residency match season in a variety of specialties (internal medicine, internal medicine–pediatrics, pediatrics, radiology, and child neurology), the authors observed that, during this season, many programs incorporated virtual social events that focused on diversity and inclusivity. Many of these events or initiatives included specific sessions for LGBTQ+ identified applicants.8,9 Through personal experiences of researching programs, interviewing virtually, and participating in social media such as #MedTwitter, the authors observed that, in addition to social hours, certain programs offered to connect LGBTQ+ applicants with residents via email or video call. This intervention created additional space to ask specific questions about the work atmosphere and program culture with less perceived risk of feeling judged or discriminated against. As the ability to identify LGBTQ+ mentors and allies has been shown to positively impact the personal and professional experience of LGBTQ+ medical trainees,1 this intervention has substantial potential to recruit and support LGBTQ+ residents.10 With these innovations, programs can connect LGBTQ+ applicants with LGBTQ+ faculty and residents who share professional interests, allowing further rapport and improved comfort level potentially greater than that formed during traditional methods of interviewing.
Virtual interviews offer additional ways for both applicants and programs to signal their identities as, or in solidarity with, LGBTQ+ applicants. In the authors' experience, some programs encouraged medical students to publicly designate their pronouns (he/she/they/etc) along with their names on Zoom (Zoom.us, San Jose, CA) or other platforms, allowing applicants to be properly gendered throughout the interview day. One author interviewed at a program which sent a survey out before the interview day that requested information, such as gender identity, pronouns, and preferred name, in order to better accommodate interviewees and connect them to residents and faculty with shared identities. This is especially important as the Electronic Residency Application Service (ERAS) does not offer comprehensive identity designations, such as nonbinary, within the application portal. Program initiatives such as these offer a novel method of connecting LGBTQ+ applicants and creating a stronger community.
Decreased Equity
While virtual interviews allowed programs to demonstrate their commitment to LGBTQ+ trainees, it is possible that virtual interactions prevented candidates from gaining a holistic understanding of program culture. For some LGBTQ+ applicants, the virtual interview process affected their ability to gauge the authenticity of programs' claims around diversity and equity. For example, in programs that did not offer dedicated, structured sessions for LGBTQ+ applicants, it is the authors' experience that it could be challenging to disclose personal identifying information (such as gender identity or sexual orientation) in order to ask important questions about the work environment. While residency programs can (and often do) share their commitment to diversity with applicants, without seeing concrete examples or participating in one-on-one conversations, it can be challenging for LGBTQ+ applicants to understand how they might actually feel in the learning environment. The main goal of the interview day is to provide the applicant with an in-depth understanding of the program; it is crucial for programs to intentionally present and discuss their work environment. The lack of in-person interactions may have affected LGBTQ+ applicants' abilities to feel certain about which programs offered an affirming, non-discriminatory work environment.
Another challenge for LGBTQ+ applicants may have been the inability to visit residency programs in person due to travel restrictions related to the COVID-19 pandemic. Without the opportunity to visit in person, it may have been harder to confirm whether a program offered a vibrant LGBTQ+ community. Desired geographic location is one of the most frequently cited considerations among US allopathic senior medical students when applying to (88%) and ranking (77%) programs.11 While geographic considerations are multifactorial for all applicants, this inability to visit new geographic locations in person may have disproportionately affected applicants with (often intersectional) marginalized identities.
Recommendations
Best practices for enhancing equity in the residency interview and Match process for LGBTQ+ applicants are essential to trainees' well-being and their ability to find a good fit for residency. To improve equity for LGBTQ+ residency applicants, we suggest 4 improvements for future recruitment, whether virtual, in-person, or a hybrid of both: (1) provide opportunities for applicants to self-identify their gender identity, pronouns, name, and sexual orientation prior to interviewing (ie, leave a space for manual input, rather than offering a drop-down list, or create a drop-down list that has been recently peer reviewed by LGBTQ-identified experts); (2) offer connections with LGBTQ+ residents, faculty, and other applicants via email or identity-focused social hours; (3) share a list of LGBTQ+ local organizations and LGBTQ-specific health training opportunities; and (4) provide training on supporting LGBTQ+ residents for all program administration involved in the interview process. Additionally, we strongly urge ERAS to include an optional section for applicants to include their gender identities, pronouns, and identification as LGBTQ+ at the time of application; this would reduce the work each individual program must do to collect data and connect applicants appropriately.
Overall, there is still work to be done to improve the equity of LGBTQ+ applicants in the residency interview season. In the coming years, residency recruitment stakeholders must continue to assess each interview season, whether in-person or virtual, and implement changes that stand to benefit applicants of all identities. Graduate medical education stakeholders should elicit routine LGBTQ+ medical student, resident, and faculty input to identify mechanisms to improve residency candidate recruitment equity and eliminate systemic bias.
