Diversity, Equity, and Inclusion Efforts in Graduate Medical Education: Identifying Opportunities for Collaborative Learning

Physician-patient racial and cultural concordance increases patient satisfaction, improves outcomes, and reduces health care costs.^1-5  In 2019, the Accreditation Council for Graduate Medical Education (ACGME) introduced diversity accreditation standards.⁶  In 2021, the Coalition for Physician Accountability (COPA) Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC) published specific recommendations to increase equity in the transition from medical school to residency.⁷ 

No standard guidance currently exists for implementation of these ACGME requirements or COPA recommendations. DEI initiatives have largely fallen on individual specialty program director (PD) organizations to develop national resources. As a consolidated group of specialty society PD associations for cross-communication and intercollaboration, the US Organization of Program Director Associations (OPDA)⁸  recognized the variability in formal program structures to improve DEI. Our DEI workgroup performed this exploratory study of DEI educational initiatives across residency specialties to describe the scope of resources and to identify gaps and areas for collaboration.

From June to September 2022, the OPDA DEI workgroup members met bimonthly over teleconference to define, discuss, and assess the GME needs and available resources for DEI training based on ACGME and COPA-UGRC standards. Workgroups were comprised of 6 PD specialty society leaders (3 medical, 3 surgical) and one Association of American Medical Colleges (AAMC) representative. After in-depth literature review and 5 iterative revisions of the survey questionnaire by the workgroup members, the final survey included 17 questions (mix of yes/no, multiple choice, and open text) on DEI topics prioritized by ACGME and COPA-UGRC. Five OPDA Executive Board members thereafter reviewed these questions for clarity and relevancy in consultation with an AAMC survey expert. The final survey compiled links to DEI resources (online supplementary data). The survey was electronically distributed twice from September to November 2022 to all 30 OPDA members, each representing a distinct medical or surgical specialty residency PD associations. Response percentages were calculated for each question. This study received review exemption from University of Chicago Medical Center Institutional Review Board.

The response rate was 73%, with 22 of 30 PD representatives (see Box) completing the survey. PD associations track resident demographics more than PD demographics (11 of 22, 50% vs 7 of 22, 32%). Most track race, gender, and geographic location. Few track sexual orientation and international medical graduate status (Table). The most common DEI implementation among PD associations is creation of DEI committees (16 of 22, 73%), with initiatives including resource development and dissemination (11 of 16, 69%), ensuring diverse representation (11 of 16, 69%), and research (10 of 16, 62%). Most specialties provide resources for underrepresented in medicine (UIM) students to aid with specialty recruiting (14 of 22, 64%), funding for visiting rotations or mentorship programs for UIM trainees (12 of 22, 54%), and resources on inclusion and belonging (11 of 22, 50%). One-third have resources for both recruitment and retention of diverse resident pools or have implemented pipeline programs for UIM students (Table). Most PD associations provide DEI curricular resources to training programs, such as addressing implicit bias, microaggressions, and allyship (13 of 22, 59%), teaching disparities in health outcomes (10 of 22, 45%), DEI in the workforce (11 of 22, 50%), and anti-racism in medicine (10 of 22, 45%). Some specialties provide faculty development training for teaching DEI concepts (14 of 22, 64%), but fewer provide training on improving health disparities (7 of 22, 32%). Many specialty PD associations provide robust resources for recruiting UIM residents, such as scholarships for away rotations, lists of programs providing support for visiting students,^9,10  funding for national meeting attendance,^11,12  recommendations for holistic review of residency applications,¹³  and DEI strategies for interview days.^14,15  Few specialties (6 of 22, 27%) issued recommendations on DEI education beyond specialty-specific ACGME requirements (Table).

Our study of DEI efforts within specialty PD associations reveal that most specialties are proactive in their DEI activities to meet ACGME and COPA standards. Many have DEI committees, application resources for UIM students/residents, and DEI teaching resources for trainees. Yet, considerable variation and duplication exist in these GME efforts, as well as critical gaps in faculty development and specific DEI content areas, which illuminate opportunities for collaborative learning within the GME community.

A surprising gap was that despite support for recruitment efforts, funds for visiting students and national meeting attendance, and recommendations for holistic review of residency applications and DEI strategies for interview days, few PD associations have resources to promote resident retention and belonging post-matriculation.^16,17  This may be key for initial resident recruitment and essential for enhancing workforce diversity. Also notable is the inconsistent tracking by specialty associations of resident and PD demographics to understand strategies and follow trends in the specialty workforces. Without this information, understanding the downstream effects of various DEI efforts, such as mentorship and pipeline programs, will be difficult. Increased transparency regarding a specialty’s DEI goals and outcomes may attract more diverse candidates to the specialty as well.

Specialty PD associations’ recommendations for educational programs may be limited by the few studies published with educational outcomes of DEI curricula for residents.¹⁸  The majority are from the last 5 years, in internal medicine and family medicine, and involve large group sessions, small group discussions, simulation, asynchronous modules, journal clubs, field trips, or self-reflections. While some content is specialty-specific, our study found opportunities for sharing resources across specialties in general topics such as allyship with minority patients/peers, bias reduction, and microaggression. Many PD associations offer specialty-specific guidelines, toolkits, and curricular materials (online supplementary data). Noteworthy robust DEI resources are from the Alliance for Academic Internal Medicine, Association of Program Directors in Surgery, and American College of Obstetricians and Gynecologists. Some specialty resources are only accessible behind firewalls or memberships, which poses a barrier to collaborative GME learning.

While these educational tools exist for trainees, much less appears to be available for faculty development on DEI education, especially in health care disparities. This gap may stem from an expectation to self-educate. Generalizable faculty development resources such as ACGME’s Equity Matters program^19,20  may be helpful for faculty to gain skills for DEI-related teaching.

This survey study is limited, as the survey was not tested for validity evidence; thus, respondents may not have interpreted the questions as intended. In aggregating the answers, some DEI initiatives were found to fit into multiple categories, which may reduce confidence in the specific percentages. In addition, the surveyed specialty representatives may not be aware of all DEI initiatives across their specialty. This area is also fast moving, and the data lack developments since 2022. Additionally, surveying DEI initiatives implemented in a top-down direction from specialty PD associations does not capture innovative or effective initiatives implemented by individual residency programs nor does it investigate the impact or outcomes of these DEI interventions.

Many specialty PD organizations appear to be actively engaging in improving workforce diversity and DEI competencies; however, duplicate initiatives were noted in the survey, and a key next step for OPDA is to create a central repository of generalizable DEI resources to share among all specialties. The online supplementary data is our first step toward this effort. In addition, considerable gaps exist such as educational materials on health disparities and equity-focused recruitment and retention strategies, which should lead to collaborative work across all specialties.

This survey study reveals substantial progress, in most specialties, to strengthen DEI within US GME. Educational gaps remain in specific DEI contents, faculty development, and curricular dissemination, which may benefit from national collaboration across specialties, to share best practices and study outcomes.

The authors would like to thank Ms. Danielle Taylor for distributing the survey and assistance throughout, David Matthews and Lisa Howley PhD from the Association of American Medical Colleges for their assistance in developing the survey, and Dr. Megan Aylor and Dr. Erin Grady for their workgroup participation and input on the survey.

The online supplementary data contains the survey used in the study, diversity, equity, and inclusion resources for graduate medical education, and a visual abstract.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

This study was previously presented an Organization of Program Director Associations (OPDA) virtual meeting, November 11, 2022.