Factors Influencing Underrepresented Minority Applicants’ Ranking of General Surgery Residency Programs

Introduction

Even when controlling for social determinants of health such as insurance status, income, age, and pre-existing conditions, numerous studies demonstrate racial and ethnic disparities in health care for minority populations.^1–3 Patients who identify as underrepresented minorities (URM) and have physicians with racial concordance report better satisfaction, compliance, and health outcomes than those who do not.^4–6 Despite the increasing diversity of both the national population and the population of matriculating medical students, only 7% of academic surgeons in the United States identify as URM, and there has been no change in this number from 2005 to 2018.⁷

Increasingly, surgery departments across the United States are implementing strategies to diversify their residency classes.⁸ However, residency programs show differing rates of success. Studies regarding residency program rank lists, in general, show that overall location and program factors (eg, morale and clinical experience) are the most influential factors in rank list for all applicants.^9,10 Women and URMs are more likely also to prioritize family and diversity factors.^9,10 However, factors specific to URM applicants pursuing general surgery programs remain unknown and understudied.¹¹

To increase URM recruitment and retention in surgical disciplines, programs must have a deeper understanding of factors important to URM candidates applying into general surgery residency. In this study, we explored factors considered by URM in creating their National Resident Matching Program (NRMP, or Match) rank order list for general surgery residency. We hope these results yield opportunities for surgical residency programs to strengthen their cohorts by improving diversity and representation in pursuit of racial justice and health equity. Specifically, we hypothesize that URM participants will prioritize factors related to diversity and inclusion efforts.

Methods

Results

Survey Results

Sixty-four students (median age 25–29, 67% female; Table 3) out of 993 total students who matched to general surgery residency programs in the NRMP in 2020 completed the survey.¹² There were 22 URM respondents, 12 of whom self-identified as Black or African American, 7 as Hispanic or Latino, 2 as Pacific Islander, and 1 as Native American or Alaska Native (Table 3). Of the 18 factors contributing to general surgery residency rank, post-graduate job or fellowship opportunities, the feeling of being wanted at the program, anticipated clinical experience, and perceived morale of residents were ranked highest among all participants. Of the list, URM residents ranked post-graduate opportunities and perceived morale of residents the highest of all factors. URM participants ranked the importance of factors related to diversity (diversity/inclusion statements, resident/faculty diversity), education (post-graduate/fellowship opportunities, academic reputation, program size, revisit opportunities), experiences (mentorship, feeling of being wanted, support of resident-led initiatives), and lifestyle (benefits/finances, spouse job opportunities, political climate) higher than did non-URM participants (p<0.05; Figure 1). Additionally, URM participants ranked certain program educational factors—post-graduate opportunities (p<0.05), academic reputation (p<0.05), program size (p<0.05), and revisit opportunities after interview day (p<0.05)—higher than did non-URM participants (Figure 2).

Figure 1. Diversity Factors in Ranking of Programs

All factors shown were significantly different (p<0.05). Median participant rating of factor importance via Likert scale shown.

Figure 2. Education Factors in Ranking of Programs

All factors shown were significantly different (p<0.05). Median participant rating of factor importance via Likert scale shown.

Table 3.

Survey Respondents’ Demographics

	All respondents (n=64)	URM respondents (n=22)
Race/ethnicity — n (%)
White	28 (44%)	12 (55%)
Asian	13 (20%)	7 (32%)
Black or African American	12 (19%)	2 (9%)
Hispanic or Latino	7 (11%)	1 (5%)
Pacific Islander	2 (3%)
Native American or Alaska Native	1 (2%)
No answer	1 (2%)
Gender — n (%)*
Female	43 (67%)	17 (77%)
Male	21 (33%)	5 (23%)
International medical graduate — n (%)
Yes	7 (11%)	3 (14%)
No	57 (89%)	19 (86%)
Marital status — n (%)
Single	45 (70%)	17 (77%)
Married	9 (14%)	4 (18%)
With significant other	6 (9%)	0 (0%)
Divorced	3 (5%)	1 (5%)
No answer	1 (2%)	0 (0%)
Have children — n (%)
Yes	59 (92%)	19 (86%)
No	4 (6%)	3 (14%)
No answer	1 (2%)
Age — n (%)
20–24	1 (2%)	1 (5%)
25–29	51 (80%)	17 (77%)
30–34	7 (11%)	2 (9%)
35–39	4 (6%)	2 (9%)
No answer	1 (2%)
First generation — n (%)
Yes	11 (17%)	6 (27%)
No	53 (47%)	16 (73%)
Low income — n (%)
Yes	19 (30%)	12 (55%)
No	43 (67%)	9 (41%)
No answer	2 (3%)	1 (5%)
Residency position
Categorical	51 (80%)	17 (77%)
Prelim-Undesignated	10 (16%)	4 (18%)
Prelim-Designated	3 (5%)	1 (1%)

There were no respondents who self-identified as transgender, genderfluid, nonbinary, or other.

URM participants prioritized a supportive learning environment during residency more than did their non-URM peers. They prioritized factors such as formal mentorship opportunities (p<0.001), the feeling of being wanted (p<0.05), and department support of resident-led initiatives (p<0.05; Figure 3). Similarly, URM participants placed greater emphasis on residency experience outside of academics, such as program benefits and finances (p<0.05), job opportunities for one’s spouse or significant other (p=0.05), and the political climate of the program (p<0.05; Figure 4). Some factors did not differ in importance between URM and non-URM participants. Among these factors were proximity to family, geographic location, anticipated clinical experience, and perceived morale of residents. Overall, URM participants rated all factors higher than did non-URM participants.

Figure 3. Experience Factors in Ranking of Programs

All factors shown were significantly different (p<0.05). Median participant rating of factor importance via Likert scale shown.

Figure 4. Lifestyle Factors in Ranking of Programs

All factors shown were significantly different (p<0.05). Median participant rating of factor importance via Likert scale shown.

Discussion

This study identified several discrete factors that URM interns value in the NRMP rank list process, including (1) diversity factors, (2) active inclusivity efforts, and (3) a supportive learning environment. The demographic distribution of age, race, and other variables in the cohort described in this study is consistent with the distribution for incoming general surgery interns in 2020 as reported by the Association of American Medical Colleges (AAMC).¹² Our data align with that of other studies, highlighting that all incoming interns prioritize post-graduate opportunities, anticipated clinical experience, perceived morale of residents, and the feeling of being wanted.^9,10 However, our data demonstrate unique factors valued by URM during the rank list process.

First, diversity factors were especially important to URM medical students applying into general surgery. URM interns cited the “diversity tax” as a concern related to the lack of persons of color in a residency program. The diversity tax describes the phenomenon that URM academics are frequently asked to take on additional, uncompensated work to address systemic racism at their institutions, such as serving on diversity committees and mentoring URMs in their field.¹³ When there are very few URMs in a program, this burden rests on the shoulders of just a few individuals. Understandably, incoming interns did not want to be put in the position of speaking on behalf of their entire race. Facing an academically and clinically rigorous program such as general surgery residency, URM interns unsurprisingly would be hesitant to take this on.

URM general surgery interns reported using visual scans of representation on program websites and on interview day as a proxy for lived values of diversity and inclusion because assessment was otherwise difficult. General surgery programs could be more welcoming to URM applicants through appropriate representation in the faculty ranks and by increasing visibility of diverse faculty on interview day and online. Rather than shying away from issues of diversity, we suggest programs lean into difficult conversations by being intentional, frank, and public with goals to increase representation and diversity of perspective. This approach aligns with URM applicants’ desire to see programs willingly discuss related efforts candidly.

Second, incoming interns also looked for evidence of inclusion initiatives. Several incoming interns expressed that some programs seemed to feel, as one participant put it, “behind on the diversity game” and thus expressed interest in URMs to increase their diversity numbers as opposed to genuinely valuing diverse perspectives. Being told that a program values diversity is not as reassuring to URMs as seeing evidence of action to promote inclusivity because of the risk that a program is a performative ally.¹⁴ Programs can signal true allyship in a way that is valuable to URM applicants by funding meaningful initiatives to address self-identified areas for improvement.

Third, the data emphasize that a supportive program environment is highly valued by URM interns. The availability of formal mentorship opportunities was a significant factor in evaluating programs for URM interns. URM interns also looked for programs that would actively support their goals. This support may come in the form of resources such as allocated funding and assistance with project development through goal-specific mentorship or protected time. Several interns noted specific interests within academic surgery and shared examples of their interviewers describing how a particular program could help them achieve goals in their area of interest.

Our data indicate that URM applicants weigh the presence of a visibly diverse and inclusive culture and facilitated mentorship opportunities heavily when making decisions about where to train for general surgery residency. Programs should lean into difficult conversations by being transparent and realistic regarding efforts to increase representation and diversity within their departments. By valuing and allocating resources toward resident-led goals, programs can create an environment that is empowering and inclusive, thus providing a supportive training environment for URM residents. This environment would benefit not only the professional growth and development of URM residents but also the surgery community at-large through diversity of thought and improved patient care.

Our study is not without limitations. One limitation is the number of interviews and surveys completed relative to the number of applicants into general surgery. Distribution was limited to targeting professional social media, mainly what was then known as Twitter. As a result, we were unable to assess response rate. Additionally, given the COVID-19 pandemic, graduating students in the United States may have been in various phases of being recruited earlier to assist with patient care during our study, so there may be a selection bias in participants who had the bandwidth to complete interviews. Similarly, interviewees during this cycle were the last to complete interviews in-person to date. It is possible applicants have different perceptions of programs’ diversity initiatives during in-person versus virtual interviewing. Given that rank lists were submitted prior to the height of the pandemic, it is unlikely the COVID-19 pandemic affected participants’ perspectives throughout the interviewing and recruiting process. Lastly, our findings are mostly applicable to underrepresentation by race and ethnicity given the lack of responses encapsulating experiences of people outside the gender binary. Despite these limitations, we believe that our study provides important, previously unknown information given that currently only 8.9% of general surgery residents self-identify as Black, African American, Hispanic, or Latinx.⁹ More research is needed on the perspective of program directors and their approach to this issue.

Conclusions

This study indicates that incoming URM general surgery interns weighed several discrete factors more heavily than did incoming non-URM interns in building their Match rank order list. These factors are (1) diversity issues including representation within the department, (2) active inclusivity efforts, and (3) a supportive program environment. To foster a more diverse residency, programs should address these factors directly through (1) elevating minority faculty and making representation a department-wide priority, (2) funding meaningful initiatives to address areas for improvement in the diversity space, and (3) listening to and supporting resident-led goals. These findings are critical for making the field of academic surgery more welcoming to URM applicants. Programs must recognize diversity issues as important; discuss them candidly; and make it a priority to address disparities directly, intentionally, and publicly.