Evidence-Based Inclusive Graduate Medical Education Recruitment Strategies

Health disparities in minoritized populations—African American/Black, Latinx, Indigenous, LGBTQ+, and individuals with disabilities—are well documented. Accrediting organizations and professional societies have recommended diversifying the physician workforce as one way to address these health disparities. Yet responding to these calls, using evidence-based approaches, can be nerve-racking and resource-challenging. Efforts are further complicated by the reality that each training program and community has its own unique diversity profile that must be strategically integrated into plans for increased workforce diversity through recruitment of trainees from underrepresented in medicine (UiM) and LGBTQ+ identity groups, as well as individuals with disabilities.

Diversifying the workforce must include the recognition that barriers to advancement remain present throughout residency and fellowship training, and a focus on mentoring and retention must be woven into each residency program's fabric.¹  Thus, increasing diversity requires an intentional focus on each step in the recruitment process. Begin by interacting with potential pathways into training and establishing a strong internet and social media presence. These activities can demonstrate inclusion and highlight UiM faculty who are exemplars in their fields, mentoring programs, and investments in trainees' success through targeted resources.^1,2 

Application review and interview practices must shift to focus on targeted variables for holistic review and acknowledgment of unconscious biases. Holistic review processes are an effective way for programs to increase the number of diverse candidates screened, interviewed, and highly ranked.²  Some features commonly used in conducting holistic reviews and their location in a candidate's application are highlighted in the Table. Interviewer implicit bias training has been demonstrated to increase UiM applicants' comfort with interview processes.^2,3  Structured interviews can minimize bias by ensuring that all candidates are asked the same questions.¹  Ultimately, program leadership must intentionally align ranking criteria with the chosen inclusion variables when creating rank lists.

To recruit a diverse group of residents and fellows:

1. Plan for success! Make diversity a priority and part of your program mission. Programs must make a public and authentic commitment to diversity, equity, and inclusion (DEI) starting at the highest levels of leadership,^2,4  with buy-in from everyone in the program. Make an ongoing financial commitment to DEI. Your program's authentic commitment should be reflected in application materials and on social media posts and website(s), and explicitly shared with program applicants.

2. Use data to track DEI recruitment priorities. Create data tracking systems for each recruitment step that highlights the specific groups you are trying to recruit, using the following: application; screening; interviews offered, accepted, and attended; number in ranked to match; and number matched. Monitor the data throughout the recruitment season for variability in applicant numbers; data can highlight where bias may be showing up in your processes.

3. Develop structures that promote DEI. Identify the key characteristics valued in your program and work with your team to design processes to elicit those characteristics throughout your recruitment and selection processes such as:

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     Blinding the application (name, photographs, medical school) during the screening process and ranking meetings

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     Developing and using a standardized applicant screening rubric by applying holistic review principles that go beyond traditional metrics and capture the characteristics your program values

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     Using a structured interview format and standardized interview question(s), including the applicant's commitment to advance DEI

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     Increasing the size and diversity of your ranking committee to ensure multiple points of view are represented. Discourage the use of vague terms like “fit,” which may hide bias(es)

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     Adding “review of the committee's final rank list” to your rank meeting checklist can assure that the list reflects the priorities set during preparation

4. Create an inclusive application process. Your recruitment experience must accurately reflect your program's environment; don't “sell” what doesn't exist at your program. If you still have DEI work to do (as we all do), share your plans with applicants. Be intentional. Ask for and use pronouns in all communications. Host affinity gatherings for applicants with residents and/or faculty who share aspects of their social identities. Invite current and recent residents to connect in one-on-one meetings with applicants. Highlight diversity as a core value during program director remarks to applicants; encourage program directors to state their personal and program commitment to continued DEI growth.

5. Mitigate interviewers' individual and interpersonal biases.Each of us has biases. Require that everyone involved with interviews and selection processes participates in antibias training with a competent trainer or completes online training from professional and specialty societies. Take and reflect on the Implicit Association Test. Highlight interpersonal biases that emerge during applicant interactions, such as “like me” bias, where we feel more positively toward those who share aspects of our social identity.³ 

1. Get department leadership buy-in. Collect and regularly review data regarding your program's impact on health disparities and training diverse faculty members. Benchmark your residency program, department faculty, and trainee race and ethnicity against national means (Pittsburgh's Inequality Across Gender and Race report, Association of American Medical Colleges [AAMC] Faculty Roster database). Setting targets and monitoring for improvement can sustain departmental commitment to diversity recruitment efforts.⁴  Highlight Accreditation Council for Graduate Medical Education requirements to sustain leadership commitments to inclusive recruitment.

2. Invest in resident success and an inclusive learning environment. Go beyond the number of faculty and trainees recruited/retained and record their successes over time. Invest in trainee and faculty success: provide culturally sensitive mentoring and resources based on individual needs (eg, board examination preparation courses, seed funding for research efforts) and foster an inclusive learning and work environment. Ask graduate medical education (GME) leaders to contract an outside team to assess the DEI culture in the program or sponsoring institution, as recommended by the AAMC.

3. Build the pipeline. Inclusive recruitment efforts can feel like a zero-sum game as UiM candidates are highly sought after by all residency programs.²  If your institution is only beginning to foster DEI, focus on the medical school level. Set up advising programs for medical students, create summer research programs for UiM students, and fund a UiM visiting medical student away rotation program. To support these efforts, utilize medical school affinity groups, which may provide an entrée for UiM medical students yearning to network with residency program leadership.²  Support GME leaders' attendance at regional and national meetings of organizations that support UiM (eg, Student National Medical Association, Latino Medical Student Association).

4. Then start all over again. DEI efforts in GME must be an iterative process. Like quality improvement projects, you must revisit your data and identify new goals to continually improve your inclusive recruitment strategies and inclusive learning environments.²