Marginalized Students Less Likely to Place in Graduate Medical Education

For most aspiring physicians, medical school is just the first step toward establishing a career. Applying to residencies, in which they will train in their medical specialties, is an expensive, time-consuming, high-stakes process. But as with many aspects of life, there are disparities in how residents are selected, according to a new Yale-led study published in JAMA Network Open.

Researchers sought to predict the likelihood of graduate medical education (GME) placement by race and ethnicity, sex, and socioeconomic status. They conducted a retrospective analysis of medical school matriculants who applied for residency from 2018 to 2021 using Association of American Medical Colleges (AAMC) GME Track Resident Survey data.

“In previous studies, we’ve really only looked at one dimension of identity, but there’s intersectionality and the compounding of multiple marginalized identities,” says Mytien Nguyen, MSc, lead author of the study. “We wanted to see how these identities came into play in the application process.

The least likely to be placed in GME were Black or African American and Hispanic male students, and American Indian or Alaska Native and Hawaiian Native or Pacific Islander female students. Black female students and Hispanic female students also had much higher rates of not placing compared to white students. These groupings correspond with AAMC’s definition of students who are underrepresented in medicine (URIM). Students covered by the data may fall into more than one of these categories.

Low-income students were also less likely to be placed, but even more so when combined with another marginalized identity. “There is a clear compounding effect of being a student underrepresented in medicine and lower income,” says Nguyen. “There is a double whammy in terms of how medicine is classist and racialized.”

Asian and white students are not classified as URIM. Although, according to a previous study conducted by Nguyen and Boatright, students who identify as Asian and male experience significant discrimination. This discrimination may explain the disproportionately high attrition rates experienced by male Asian students compared to their white peers. Similarly, in the present study, Asian males were less likely to place in GME than their white male peers.

“Based on the data we have, it is unclear what’s actually driving the higher rates of unsuccessful GME placement,” says Dowin Boatright, MD, MBA, MHS, assistant professor adjunct of emergency medicine, another researcher on the study. Boatright and Nguyen suggest this lower initial GME placement for URIM students may impose a minority tax, requiring some students to prolong their time to independent practice, limiting their lifetime earnings potential, and restricting physician workforce diversity.

In future studies, Nguyen and Boatright would like to assess more aspects of identity such as disability status and sexual identity but are limited by the identifiers that the AAMC GME Track Resident Survey collects.

Nguyen and Boatright insist that improving GME placement rates for students who are disproportionately affected needs to happen intentionally at the structural level. For residency programs, Nguyen recommends examining which aspect of an application is being prioritized — test scores, awards, publications, volunteerism, and so on — and giving more balanced consideration to all components.

“Residency programs need to start looking more holistically at the students,” says Nguyen. “Residency programs should also make spaces for diverse students, and not rely on evaluations based on how eloquently the individual speaks, for example.”

Aside from the judgment of the student’s application, a student’s social and financial capital can also affect placement. Nguyen and Boatright believe institutions can take more responsibility in leveling this disparity. “From what I’ve seen, there are a lot of subtle, behind-the-door conversations that happen during the whole application process,” says Nguyen. “Programs need to be more conscious that many disadvantaged students, namely URIM, female, and low income, are coming with less social capital.”

Boatright says that failing to gain a residency can also be self-perpetuating. “There is definitely a stigma associated with not placing,” he says. “When you’re applying the next year, those places will know, and the likelihood of someone matching is going to be much lower.” Regarding financial capital, Boatright adds, “Without question, I think students all students would benefit from some relief from the financial burden to apply.”

Moreover, Nguyen and Boatright believe the Accreditation Council for Graduate Medical Education should provide more oversight in the process. They recommend weaving their diversity standards into accreditation by assessing programs on the diversity of matriculants and placement into particular specialties by applicants’ sex, race/ethnicity, and their intersections.

Nguyen points to the Liaison Committee on Medical Education as a model of success. “The LCME has implemented its diversity standards which have led to an increase in recruitment of URIM and female students into medical school,” she says. "A similar accreditation standard at the graduate medical education level may prove to be highly effective.”