Program Director’s Corner – August 2019

A Holistic Process for Recruiting and Interviewing Endocrinology Fellows: a Mechanism to Increase Diversity

Ricardo Correa MD, Es.D and Karyne Vinales, MD
University of Arizona College of Medicine-Phoenix

The United States health care system is fraught with racial/ethnic and gender disparities.^1,2 The data in endocrinology is weak, but a few studies that compared different medical subspecialties show that our specialty in some geographical regions lacks diversity, when compared to the population of the same area. While the underlying reasons for ongoing inequity are countless, lack of diversity in the physician workforce is a significant contributing aspect.^2,3 Physicians and trainees from underrepresented minority groups are more likely to care for traditionally underserved minority patients,^4,5 yet diversity among the US healthcare workforce has not kept pace with the rapidly changing demographics of the US population.

Even though we as a physician community have known about this problem, there is a lack of research in the graduate medical education arena regarding how to increase the diversity of the trainee workforce. The AAMC has established what is called “holistic review” to tackle diversity in undergraduate medical education, and define it as “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics.” ^2,6

Several GME programs⁷ have been working on projects intended to increase diversity, mainly when they are located in cities with a very diverse population, including Houston, Phoenix, Los Angeles, Miami, and New York.

During this time of the year, we are receiving applications for our fellowships. We know that many of you have already a plan in place on how to choose applicants for an interview and how to conduct the interview. Also, we know that increasing diversity in small programs like many of our fellowships is not an easy task to accomplish. We want to discuss in this article some strategies that you can use during the application review and on the interview day to address diversity in your program. This is what we call a “holistic process and interview.

The recommendations that we are proposing in this article are early stage and do not have strong evidence, but we can assure all of you that we are working on a stronger process for reviewing and selecting applicants. We expect to have data to present to the entire APDEM community in the upcoming years.

First, we will start with the selection process⁸:

1. USMLE scores: We understand that many programs use the USMLE score as a filter for the selection process. We recommend that besides looking at the USMLE scores as the only entity, you use some modifiers such as: (1) prior leadership experience and core values of the candidate that align with the mission and vision of your institution (this can be found in the applicant’s personal statement); (2) commitment to underserved or underrepresented populations such as volunteer work during residency; and (3) balanced representation of the community where your program is located. A scoring method that has been useful in residencies is to add 2 points for each of the above items.⁶ Using this technique, you can decrease the bias of relying just on an exam but allowing for interviewing applicants that have other abilities that will be good for your fellowship.

2. Letter of recommendations (LORs): Depending on the number of applications that you receive, it can be challenging to read all the letters of recommendation. But, with the new Internal Medicine (IM) Program director standardized letter of recommendation, you will have a better understanding of the applicant’s achievements. We understand that at this point, not every IM Program director uses the standardize LOR and, in those cases, you will need to rely on your ability to obtain the essential data from the LOR. We recommend using the Alliance for Academic Internal Medicine (AAIM) resources on how to appraise a LOR.

Second, the interview process⁸:

3. Training of the interviewers: Faculty members involved in the fellow selection and interview process should go to an unconscious bias training session before the interview season. This training will facilitate discussion about implicit bias, microaggression, and its potential impact on recruitment. Also, this training will create a safe discussion that will also help your program. The Office of diversity and inclusion from your institution can do this training, or there are many resources in the AAMC webpage. If you need something a little bit easier please email us, and we can provide a small presentation on this topic.

4. Ask specific questions to the applicant: We recommend distributing among the interviewers’ certain questions that will address specific competencies of the applicant. Previously, there has been no standardized questionnaire for this (we are working on this during this interview season), but you can create your questions. The main topics that this questionnaire should address are: (1) the ability of the applicant to work in teams, (2) approaches to problem solving, resilience, (3) personality, and (4) capacity to adapt to changes. We recommend that at least two interviewers ask one of the topics above to decrease subjective bias.

5. Use one member of the Diversity and Inclusion (D&I) Office or Committee from your institution to be part of the interview (the officer doesn’t necessarily need to be an endocrinologist): The main focus of this faculty member will be to evaluate the applicant’s response and reaction to a standardized case about discrimination. We have created a scenario that we can provide to you. Besides having an external faculty that understand, involving D&I will make your interview a holistic process.

6. Include your fellows in the interview process: Fellows can provide valuable insight into potential future co-workers. Peer-to-peer communication has been proven to help in the hiring process in other areas (not specifically in medicine). A technique that has been proven in residency programs is that residents (the ones that were involved during that day with the applicants during breakfast, lunch or particular time) answer the following two closed-ended questions for each applicant as a consensus (one evaluation from all the fellows): (1). Do you feel that this applicant will be a perfect fit for your program? And (2) Do you have any concerns or red flags about the applicant? We are currently applying this practice with our fellows and asking for their feedback on potential candidates (as a pilot project).

While we understand that the suggestions provided above to create what we consider a holistic review process and interview have not been evaluated, our team firmly believes that we as an endocrine program director community should lead this change in our country. This is the first step, and we would welcome additional dialogue with our peers that are interested in improving the interview process. If we consistently use the same protocols, and collect results through scientific protocols, our results could support a positive change not only in endocrine field but in the entire GME community.

For more information about this or if you have any question, please contact Ricardo Correa (ricardocorrea@email.arizona.edu) or Karyne Vinales (karynevinales@email.arizona.edu)

References
1. Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003.
2. Omowunmi Aibana, Jennifer L. Swails, Renee J. Flores, LaTanya Love. Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education. Acad Med. 2019;94:1137–1141.
3. Agency for Healthcare Research and Quality. 2016 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; July 2017 2017.https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr16/2016qdr.pdf. Accessed August 1, 2019
4. Wayne SJ, Kalishman S, Jerabek RN. Timm C, Cosgrove E. Early predictors of physicians’ practice in medically underserved communities: A 12-year follow-up study of University of New Mexico School of Medicine graduates. Acad Med. 2010;85(10 suppl):S13–S16.
5. Association of American Medical Colleges. Addressing racial disparities in health care: A targeted action plan for academic medical centers. https://members.aamc.org/eweb/upload/addressing%20racial%20disparaties. pdf. Published 2009. Accessed August 1, 2019.
6. Association of American Medical Colleges. Diversity in the physician workforce: Facts and figures 2014. http://www.aamcdiversity factsandfigures.org. Accessed August 1, 2019.
7. Java Tunson, Dowin Boatright, Stephanie Oberfoell, et al. Increasing Resident Diversity in an Emergency Medicine Residency Program: A Pilot Intervention With Three Principal Strategies. Acad Med. 2016;91:958–961.
8. University of Arizona College of Medicine-Phoenix, Diversity and Inclusion Committee. GME program. Endocrinology, diabetes and metabolism project. Personal Communication.