An Analysis of Underrepresented in Medicine Away Rotation Scholarships in Surgical Specialties

Diversity is essential in the medical profession, shown to benefit both medical education and underrepresented minority patient outcomes.^1-9  A diverse student body can foster cultural awareness through interactions with different students and faculty, creating a prosperous learning environment prepared to treat a racially and culturally diverse patient population, handle the unique challenges of a multicultural population, and eliminate existing health care disparities.¹  As such, efforts to improve diversity in medicine have become an important initiative across specialties. The Association of American Medical Colleges (AAMC) defines underrepresented in medicine (UIM) as racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population, including African Americans, Hispanics, American Indians, Alaska Natives, and Native Hawaiians.¹⁰  In 2019, while 33.4% of the US population consisted of these racial and ethnic groups,¹¹  only 14.3% of surgical residency matriculants did.¹²  Furthermore, there are significantly fewer UIM faculty in surgical specialties compared to many primary medical specialties.¹³  Although there is a lack of diversity in surgical specialties, minimal improvement has been made to increase racial diversity.^14-19  Therefore, scholarships may be an initiative to start improving, recruiting, and fostering diversity within residency programs. Previous studies have indicated that extramural rotations positively correlated with a student's ability to match into a surgical specialty, since it provided the applicant an opportunity to show interest in a program, demonstrate surgical abilities, and receive a letter of recommendation from a faculty member.^20-23  According to a survey of 2015 Match applicants in all specialties, 67.4% of the surveyed applicants completed a visiting extramural rotation, and 36.0% matched at the program where they completed the rotation.²⁴  UIM scholarships for visiting fourth-year medical students became increasingly popular and successful in cultivating diversity, such as within emergency medicine residency programs.²⁵  While extramural rotations are important, they are expensive for the applicant. Additionally, one of the main reasons applicants' chose to forgo an extramural rotation was because of the cost.²⁶  According to a 2015 survey of plastic surgery residency applicants, the average cost of an extramural rotation was $3,591.²¹  Additionally, a higher proportion of UIM medical students graduate with debt, specifically African Americans.²⁷  Therefore, UIM visiting student scholarships can provide necessary financial assistance to cover travel and housing accommodations, so the program may receive applications from socioeconomically diverse populations.

Due to the small percentage of UIM surgical resident matriculants,¹²  residency programs may be competing to attract the same students to their programs for extramural rotations, applications, and interviews. Students may be more inclined to apply to extramural rotations at institutions with scholarships due to the financial burden of the extramural rotations. However, this may create more disparities since only programs with more resources may offer scholarships. Therefore, it is important to understand which programs offer scholarships.

Programs were categorized based on variables featured in previous literature that have been identified as factors that impact recruitment or methods of recruitment.^28-31  The purpose of the study was to examine the prevalence of UIM visiting student scholarships for surgical specialties. This study identifies scholarship opportunity differences between surgical specialties and program types.

The Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs in general surgery, neurological surgery, orthopedic surgery, otolaryngology, integrated plastic surgery, integrated thoracic surgery, urology, and vascular surgery were identified from the ACGME Accreditation Data System in July 2021.³²  The identified institutional and program websites were examined, and data were independently collected and verified by 2 authors (S.L.B., C.W.). These specialties were chosen because they are primarily traditional general surgery and surgical subspecialties and had publicly available data.

Residency programs were classified by the following: program size (postgraduate year [PGY]-1 class size), program type (community, community with university affiliation, and university), and region (East North Central, East South Central, Mid-Atlantic, Mountain, New England, Pacific, South Atlantic, West North Central, West South Central, and Territory) using the Fellowship and Residency Electronic Interactive Database (FREIDA).³³  The National Institutes of Health (NIH) funding level for each program was obtained from the Blue Ridge Institute for Medical Research (BRIMR) database.³⁴  These data were not available for integrated plastic surgery, integrated thoracic surgery, or vascular surgery.²⁵  Program reputation and the population density of the program's location (urban or rural) were assessed using Doximity.³⁵  Doximity is a database of residency program information populated by annual surveys of practicing physicians.³⁵  Program reputation was stratified into 2 groups: top 20 versus not top 20 based on Doximity ranking. Reputation was not accessible for integrated thoracic surgery and vascular surgery residency programs on Doximity.³⁵  Funding was assessed as a categorical variable by stratifying into 2 groups—programs within the top 40 most funded by NIH and not top 40. According to FREIDA, 30 programs were defined as military residency programs, which were excluded from our analysis.³³  Military residency programs reimburse students for up to 2 extramural rotations provided they are part of the Health Professions Scholarship Program.³⁶  Since the scholarship is only available to individuals within the military, these programs were excluded from the analysis.³⁶ 

Residency program and institution webpages were identified using a Google search with the keywords “institution + specialty + away rotation scholarships.” Scholarships were categorized by the way UIM was defined, the number of funds provided, and the scholarship application requirements.

We directly calculated the diversity of each surgical specialty using the Simpson's Diversity Index (SDI).^37,38  This is a metric that assesses the diversity, evenness, and richness of a specialty's population using the exact count of each ethnicity group as the following: American Indian/Alaska Native, Asian, Black/African American, Hispanic/Latino, Native Hawaiian, White, and multicultural. As the SDI increases, there is more diversity. This would allow us to calculate for correlations between specialty diversity and scholarship rate. We utilized the SDI on surgical residents.³⁷ 

Univariate analyses were performed using SPSS 26 (IBM Corp, Armonk, NY). A multivariate regression analysis was also performed. A P<.05 was considered statistically significant.

Institutional Review Board approval was not required as the data was publicly available, did not involve human subjects, and does not contain any sensitive information.

In total, 8 surgical specialties and 1058 programs were analyzed. While 314 (29.7%) programs had a UIM visiting student scholarship, this was as high as 46.0% (29 of 63) in vascular surgery and 62.1% (18 of 29) in integrated thoracic surgery (Figure). General surgery and orthopaedic surgery had the lowest percentage of total programs offering scholarships (21.9%, 24.9%, respectively; Table 1). On average, the amount of scholarship funding offered was $1,852.25±633.03. Integrated plastic surgery scholarships had the most funding ($2,007.69±474.90; Table 1). Of the programs that offered scholarships, the majority had a PGY-1 class program size of 3 or more residents (68.5%, 215 of 314) and were university programs (78.3%, 246 of 314), and most commonly were located in the East North Central region (23.6%, 74 of 314) and urban areas (93.8%, 244 of 260). When examining each of 6 specialties' top 20 list, 85 programs across the 5 specialties offered scholarships. Overall, across 6 specialties on Doximity, 85 programs on the top 20 list offered scholarships. Of the 5 specialties on the BRIMR list, 106 programs on the top 40 NIH-funded list offered scholarships. Of the 314 programs that had a UIM visiting student scholarship, UIM was defined in myriad ways, including the AAMC definition (46.2%, 145 of 314) as the most common description. The most common scholarship requirements (42.7%) included the compilation of academic information (USMLE Step 1 score, transcript, or CV), personal information (photo, race, family history, birth date, or contact information), a personal statement, and a letter of recommendation. Although the majority of the scholarships gave clear guidelines and descriptions, 27 definitions of UIM (8.6%), 61 application requirements (19.4%), and 47 stipend amounts (15.0%) were unspecified.

Univariate analysis demonstrated that the smaller programs were less likely to have UIM visiting student scholarships (P<.001; Table 2). As program size increased, from a PGY-1 class of 1 to 18 residents, there was an increase in 3.3% of UIM visiting scholarships. University programs were more likely to offer scholarships (P<.001; Table 2) in comparison to the community- and university-affiliated programs. Population density of the program's location was not associated with the prevalence of UIM visiting student scholarships (P=.13; Table 2). A significant difference was found among the number of UIM visiting student scholarships across the regions (P<.001; Table 2). Top ranking programs (defined by Doximity reputation ranking) were more likely to offer a UIM visiting scholars program (OR 5.206; 95% CI 3.483-7.781; P<.001; Table 2) and the top NIH-funded programs (defined by BRIMR database) were more likely to offer a UIM visiting scholars program (OR 5.153; 95% CI 3.667-7.241; P<.001; Table 2).

When assessing the SDI, vascular surgery was the most diverse surgical specialty in 2020 (SDI=0.60), while orthopedic surgery was the least diverse surgical specialty in 2020 (SDI=0.42; Table 3). A simple linear regression analysis was performed showing no correlation between scholarship frequency and SDI (R²=0.04, P=.65). Multivariate analysis was also performed to assess the variables that affect scholarship rate (Table 4). After adjustments from our analysis, we found that there were significantly more UIM scholarships available in all sub-surgical specialty residency programs compared to general surgery residency programs. As program size increased, these programs were more likely to provide UIM scholarships (P<.001; OR 1.5 [1.3-1.8]). Programs in the top 20 for reputation were more likely to have UIM scholarships (P<.001; OR 3.0 [1.7-5.3]). Community-based residency programs provided fewer UIM scholarship opportunities on their websites relative to university-based programs (P=.04; OR 0.4 [0.2-0.9]). The location did play a significant factor in some regions for providing UIM scholarships relative to the Mid-Atlantic region. Factors that did not have a significant impact on UIM scholarships were NIH funding status and population density.

This current study assessed the prevalence, accessibility, and details of UIM scholarships offered on surgical residency program websites. We found that 22% to 62% of graduate medical education surgical programs currently fund and promote UIM visiting student scholarships, depending upon the specialty. Larger, more reputable training programs had higher rates of offering UIM scholarships although no correlation between specialty diversity and UIM scholarships was found. Our analysis demonstrated that several scholarship programs did not provide clear guidelines or important details, like stipend amounts, on their websites.

In a study completed in 2019 that analyzed general surgery residency program websites, university programs were more likely to incorporate diversity and inclusion content in their websites compared to non-university programs.³⁹  Additionally, our analysis found that university programs were associated with offering more scholarships. Therefore, it appears that university programs may be more attuned to the importance of diversity initiatives within residency recruitment. Scholarship opportunities could be more expansive to include a greater variety of programs, including but not limited to non-university programs. An analysis of 10 general surgery programs found that UIM applicants received a disproportionately smaller percentage of interview invitations, highlighting the current challenges that some general surgery programs have in achieving a diverse group of residents.⁴⁰  Thus, programs must find ways to foster and recruit a diverse group of applicants. Additionally, in 2019, 87.2% of general surgeons were located in urban areas.⁴¹  Urban areas have a more racially and ethnically diverse population than suburban areas,⁴²  so these scholarships in the urban areas are an important initiative to recruit a diverse group of residents to reduce racial and ethnic discordance.

Offering UIM scholarships also displays a program's dedication to cultivating a diverse community. According to the 2017 National Resident Matching Program Applicant Survey, 37% of applicants in all specialties considered the cultural, racial, ethnic, and gender diversity of the institution an important factor in selecting programs to apply.⁴³  Although there are numerous methods to promote diversity initiatives, including social media, the majority of prospective applicants use program websites to find information.^44-46  Thus, we utilized both program and institution websites to search for UIM scholarships. While these scholarships may showcase the program's commitment to diversity, there is a limited number of UIM applicants applying to these positions. Therefore, it is important to also implement other initiatives earlier in a student's medical school career, for example, mentorship programs that are focused on rotation choices, the field of practice, career trajectory, and research.⁴⁷ 

This study has several limitations. This is a cross-sectional study, so available scholarships may change over time. The data were only collected from publicly available information on the program and institution websites and is likely limited by missing scholarship information on some websites. NIH funding was collected as a proxy for overall program funding, but this information was not available for 3 of the specialties. Similarly, Doximity's reputation rankings were not available for 2 of the specialties and these rankings are subjective and prone to bias. It is unknown whether programs that offer these scholarships in surgical specialties have an increase in the number of UIM residents, although, in an analysis of emergency medicine programs, they were found to be helpful.²⁵ 

Additional studies should be performed to determine what impact offering such scholarships has on the goals of achieving greater diversity in surgical residency programs. Such programs are likely one of many interventions required to help recruit and promote UIM students within the surgical fields. Further action is needed to better understand how the diversity of both UIM students as defined by the AAMC and other underrepresented groups, for example, LGBTQ+ and socially, economically, or educationally disadvantaged students, can be increased.

UIM extramural rotation scholarships varies greatly across the surgical specialties and does not correlate with specialty diversity.