RYSEFAX: A Virtual Recruitment Initiative Targeting Internal Medicine Fellowship Applicants Committed to Program Inclusion Open Access

Diverse physician teams improve health outcomes, access to care, and perceptions of quality of care for patients; patients fare better when their care is provided by diverse teams, with improvement in team communications, innovation, and risk assessment.^1,2  In 2019 the Accreditation Council for Graduate Medical Education (ACGME) expanded the Common Program Requirements³  to include expectations that programs and sponsoring institutions participate in mission-driven and systematic recruitment and retention of a diverse workforce. Many talented candidates seek inclusive training environments and may be more likely to select programs seeking to recruit diverse trainee cohorts.⁴  In addition, decreased diversity in representation among underrepresented in medicine (URiM) fellows has been reported in fellowship matriculation. Representation among Black accepted fellows (4.6%) increased from 2008 to 2018 (+1.2%) but was still lower than their representation among internal medicine (IM) residents (5.6%).⁵  Representation of Hispanic resident applicants and fellows has seen minimal change.⁵ 

Most published descriptions of programs developed to enhance recruitment of graduate medical education trainees center on residency programs, with little or no attention to the unique perspectives of fellowship applicants. Fellowship applicants may have different concerns compared to residency applicants, such as a greater focus on research opportunities, subspecialty-specific training, mentorship, and job placement. Physicians trained in fellowship often pursue employment in academic centers and therefore can affect the education of learners throughout their medical career; their presence improves medical care to diverse communities and patient populations.⁶ 

We aimed to develop a virtual recruitment and engagement program designed for applicants to IM subspecialty fellowship programs and to assess feasibility and acceptability, as well as potential effects on recruitment to our fellowships.

In 2020, leadership from the Emory University Department of Medicine’s (DOM) RYSE (Represent, Support, Elevate) Council worked collaboratively with our fellowship program directors to develop a virtual recruitment and engagement program designed specifically for individuals considering post-residency fellowship training in our programs. The audience included applicants to 8 of our ACGME-accredited fellowship programs: cardiology, digestive diseases, endocrinology, hospice/palliative care, infectious diseases, pulmonary medicine and critical care, renal medicine, and rheumatology. The program was originally called the Minority Fellowship Applicant Experience (MFAX). Since 2023, it was renamed RYSEFAX, to include all applicants seeking to learn more about our diversity initiatives and commitment to health equity.

From 2020 to 2022, fellowship program leadership invited all self-declared URiM applicants who had interviewed in their respective programs for matriculation in the subsequent year’s cohort (eg, 2021, 2022, and 2023); since 2023, fellowship program leadership has invited all interviewed applicants. At the time of publication, URiM information on the National Science Foundation is no longer publicly available through the National Institutes of Health. However, URiM was defined using the National Science Foundation framework of being underrepresented in health-related sciences on a national basis, including Black or African American, Hispanic or Latino, American Indian or Alaska Native, Native Hawaiian and other Pacific Islander persons.

The virtual program is held annually in November. Prospective fellowship applicants meet with current fellows, faculty (both with and without URiM backgrounds), and RYSE leadership. Virtual meetings include one-on-one sessions between prospective fellows and subspecialty faculty and group conversations with more than one faculty member. Initially the program included a 1.5-day schedule and was streamlined to a half-day session (approximately 4 hours) to better align with prospective fellows’ schedules and in response to their feedback in subsequent evaluations.

Primary components included an introduction to the DOM chair, discussions with fellowship and diversity, equity, and inclusion leaders, breakouts with current fellows, and conversations with mentor-mentee teams (see Table 1 for sample RYSE agenda). Specific interventions and outcomes demonstrating the department’s commitment to health equity and supporting a diverse workforce were also shared with participants.

To assess the perceived value of our program, we sent participants a short survey (7 multiple-choice items and 1 open-text field; online supplementary data). Participants were asked to complete the survey approximately 3 weeks after the session and, notably, after rank lists were finalized and submitted. Survey data were analyzed in Microsoft Excel using descriptive statistics, and we performed thematic analysis of open-ended responses.

As a program evaluation activity this study met the conditions for exemption for institutional board review at Emory University.

Since implementation, 721 individuals were invited to RYSEFAX, 158 attended, and 50 applicants who self-identified as URiM subsequently matched with one of our fellowship programs (Table 2). Of the 158 applicants who attended the sessions, 22 (14% of attendees) responded to the post-program survey (online supplementary data). The survey respondents reported generally positive reactions to RYSEFAX, and their interest in participating in a fellowship in our department rose from a mean of 3.4 prior to 3.6 after participation (scale, 0=not at all interested to 4=extremely interested). Nineteen of 22 respondents (86%) indicated that participation increased their likelihood of seeking future employment within our department. All respondents ranked our institution following program attendance.

Sessions required approximately 80 hours of planning and logistical efforts by a staff administrator per year, 16 hours by program leaders to design and implement the program, and 2 to 3 hours of volunteer time from participating faculty and fellows.

Innovative methods for attracting candidates who prioritize inclusion and diversity in subspecialty fellowship recruitment can contribute to inclusive and diverse training programs, with a resultant diversified medical workforce. The RYSEFAX virtual program was developed to highlight our institution’s commitment to diversity and equity and to allow for meaningful interactions between current trainees and faculty with prospective fellowship applicants. This program, initially intended to improve recruitment of URiM applicants, was expanded to include all interviewed applicants. There was sustained participation over 3 recruitment cycles, and the program appeared to enhance interest in and ranking of our fellowships.

The findings are limited by the low response rate to the survey; only applicants with highly positive impressions of the session may have responded. The sessions were conducted as part of a large DOM with an established commitment to inclusion and diversity and may not be as feasible for smaller departments. The voluntary nature of participation does not permit conclusions about whether the program affects ranking decisions or Match outcomes.

The virtual arena allowed for the sharing of academic, personal, and other lived experiences, with bidirectional conversations beyond standard fellowship interview interactions. A virtual venue reduces cost and time considerations for the program and applicants, and more flexibility for faculty attendance. However, holding the program once per recruitment cycle may limit participation by applicants. The RYSEFAX program may not work well as a stand-alone inclusion and diversity intervention but may serve best to amplify an institution’s overall inclusion practices and diversity initiatives

Next steps will include gathering more information about program effectiveness, such as applicant engagement, through qualitative methods and surveys. We are considering additions, like virtual tours and prerecorded informational videos. It is important to determine whether this virtual program strengthens our institution’s reputation for diversity and inclusion among institutions beyond internal medicine.

Virtual fellowship recruitment and engagement programs can engage subspecialty fellowship applicants, strengthen institutional reputation, and be a meaningful component to fellowship recruitment.

The authors would like to thank John Otis Blanding, Keia Dodd, Joanna Bonsall, MD, PhD, and the RYSE (DEI) Council.

The online supplementary data contains the aggregate survey feedback from MFAX/RYSEFAX participants, 2020-2023.

This work was previously presented as an abstract at the Emory Department of Medicine RYSE second annual Health Equity Day, May 17, 2022, Atlanta, Georgia, USA.

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

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