It’s a common refrain that higher education’s commitment to diversity is performative. But there isn’t a blueprint on how to overcome barriers and turn platitudes into practices.
A pair of new papers studying how to improve diversity, equity, and inclusion in medical schools and medical-residency programs tries to bridge that gap, offering administrators across higher ed ideas for change that might stick.
The two studies examined the work as seen on the ground: in the admissions offices and in the halls of the leadership within the stubbornly inequitable field of medicine. One study identified successful strategies to improve DEI in medical-residency programs. The other paper examined the experiences of medical-school admissions leaders when they attempted to increase diversity in their programs. Both appeared in JAMA Open Networks this year and shared several authors.
Michelle Ko, a professor of health policy and management at the University of California at Davis, led the research on admissions leaders. Ko said her study was prompted by stagnating numbers of medical professionals from diverse backgrounds.
A decade into her research on diversity in medical education, “the numbers were still really not changing very much,” Ko said. “We’re still having the same conversation. What is going on?”
While higher ed’s push to increase diversity has been a decades-long struggle, STEM programs have evolved at an even slower rate. The reasons vary from a lack of diverse applicants to a lack of resources to an abandoning of commitments after a leadership change. But most institutions, these researchers say, could benefit from a road map on how to improve DEI.
Gold Standards of DEI Practices
Many best practices highlighted in the study of medical-residency programs were “very simple and wouldn’t require a lot of resources, but probably would have a significant benefit,” said Dowin Boatright, an emergency-medicine doctor at the NYU Grossman School of Medicine who led the study.
The key, the researchers found, was crafting a DEI-focused mission for the program. Then, evaluating applicants holistically against that mission naturally followed, as did retaining diverse faculty members. Reviewing applicants holistically based on their match to the mission of the program, rather than focusing on test scores, was one such strategy. Others included partnering with local community colleges, training admission interviewers on implicit bias, and forming a representative DEI committee for the program.
More resource-intensive strategies — called “aspirational strategies” by the researchers — included creating a curriculum on DEI and health equity, and involving local community members in the residency-recruitment process. Compensating residents for DEI work beyond the residency-program requirements and sponsoring outreach events with diversity-focused groups or programs also fell under the aspirational category.
Many exemplar programs kept meticulous records on their own diversity metrics. This struck Boatright, who did not expect programs to follow potential recruits’ progress through their education. “It seemed like they were making data-driven decisions light years ahead of what I expected,” he said.
Boatright and a collaborator, Tonya Fancher at UC-Davis, began this study following a 2019 decision by the accreditation board for medical-residency programs, the Accreditation Council for Graduate Medical Education, to add a diversity standard to its accreditation process. Residency programs needed to have a policy to recruit and retain individuals from diverse backgrounds or “jeopardize losing accreditation and having their program shut down,” Boatright said.
“People weren’t really aware of how to meet this accreditation standard, and especially in a best practice or even evidence-based way,” said Boatright.
Yet some programs broke the mold, making tangible improvements to their diversity. In 2020, the accreditation council launched an award to recognize outstanding efforts, and the applications yielded useful qualitative data on DEI strategies for the researchers.
“This gave us an opportunity to look at some of the programs that were considered to be very successful in their efforts to recruit and retain diverse individuals and identify some of the recurring policies and cultural aspects of those programs,” Boatright said.
Researchers classified best practices as foundational or aspirational in order to help programs identify what was doable. “You learn about all these different things to do, but really, how do you pick and choose what’s doable?” asked Fancher, an internal-medicine doctor and UC-Davis’s associate dean of workforce innovation and education quality improvement.
Deborah Willis, assistant vice provost for equity, inclusion, and academic affairs at the University of Michigan at Ann Arbor, appreciated the breakdown in strategies. “Breaking them into two different categories is important because it meets the school where they are, and allows them to determine how much they want to invest,” Willis said.
Willis noted a decline in applicants for the diversity award, from 22 in 2020 to 7 in 2021 — perhaps due in part to the cooling temperature toward DEI practices. “Those of us who do this work know that we’ll have these peaks and then the wane in interest, and then peaks and then wane in interest,” she said.
The numbers might also reflect how few residency programs were focused on DEI efforts prior to the diversity-accreditation standard, Boatright said. “There was a core group of programs that have historically been very active in this DEI space,” Boatright said. “And quite honestly, I don’t know that many other programs are doing much of anything.”
The 2022 award applications will arrive in the next several weeks. The long-term goal of the study is to examine diversity data from the programs for years to come.
The Weight of DEI Efforts
As the accreditation standard forces residency programs to adjust, medical schools continue to face a similar pressure to increase diversity in their student populations — without a clear threshold to attain.
In the study conducted by Michelle Ko and her colleagues, admissions leaders pointed to many barriers they faced when attempting to increase diversity at medical schools. Many of the 39 admissions leaders interviewed from 37 medical schools listed changes in leadership and shifting priorities as primary barriers to improving DEI.
Others mentioned the drive toward diversity had blinded leadership to unresolved racial inequities. Another barrier was a lack of DEI policies and accompanying resources, which many interviewees said were necessary to turn diversity-related statements into actions.
Test scores also hindered the admissions leaders’ DEI work. Senior leadership prioritized MCAT scores, in part because of the US News & World Report rankings, which narrowed how medical-school applications were viewed. Interviewees also reported the advantages that social and political connections may provide in the review process for medical-school applicants.
Despite the word “diversity” buzzing around the rest of campus, admissions leaders felt their office was the only place that had made substantial changes to improve diversity. “Conversation among … admissions and outside admissions, is that diversity ... is a check box, that it’s just counting bodies and not really supporting folks,” one admissions leader said.
Deborah Willis of the University of Michigan, who was not involved in the study, understands their frustration. “I do think it needs to be a shared, systemic priority,” Willis said. “We’re focusing on diversity, but then the inclusion piece is not there. A lot of times the equity piece is not there.”
But there are ways to improve diversity by changing for whom and how the admissions process works, the admissions leaders reported to Ko and colleagues. Instead of selecting students based on how well they perform on standardized tests, some interviewees wanted to evaluate students based on how well they would perform as a medical doctor in the future.
“If you have a specific mission-based program, then the way that you evaluate your applicants is based on their fit for that mission,” Ko said.
As higher ed aims to create more equitable campuses, admissions is just one piece of the puzzle. Instead, the admissions leaders stressed, the whole institution should be held accountable for improving diversity.
