"You've heard how successfully each panelist matched for residency and you've probably assumed that you can't relate to us. We've all experienced struggle and triumph. I hope by sharing our stories you see yourself in them." I shared these words with prospective pediatric applicants in a recent virtual webinar. Every year, I seek out a couple of people to help through the application process, but once I stumbled into a group chat for black pediatric residency applicants, I knew something bigger was necessary.
Within a week, four pediatric residents, Drs. Adrienne Smallwood, Chineze Ebo, Christine Cummings, and Xavier Williams, and I organized our first group mentoring session with over 80 medical students from racially underrepresented backgrounds in medicine (UIM) from 40+ medical schools across the country.
I also shared the words that cast a dark shadow over my residency application process before it even began: "Don't get your hopes up." Every pediatric applicant at my medical school was assigned an advisor to help them decide what programs to apply to and how many applications they needed to successfully match, based on a review of grades and test scores. As a Northern California native, I stated my preference to match close to home. My advisor told me to temper my expectations: "Programs like UCSF and Stanford are small and competitive. They can be pickier about your board scores."
I received a 220 on Step 1 (a passing score is 194). It didn't compare to the 250 average my medical school boasted, but I thought it was solid. Now, I wasn't so sure. I left the meeting feeling deflated. In a panic, I applied to a last-minute away rotation hoping I could prove myself to the programs I was just told could be out of my reach. With no spots left, I had to trust my application would be enough.
The comment section of our virtual webinar filled with similar stories: "I have had this advisor." "This sounds like most pre-med advisors too." "This advisor is like everyone at my school."
My experience is not unique. Others have been in the same seat where their dreams were discouraged. Were it not for my pediatrician father's reassurance at every step, his stories of succeeding in spite of rejection and failure, I doubt I would be a physician today. UIM physicians have all persisted with the help of our families cheering us on, peers in the struggle with us, and the promise of serving our communities.
I received interview invites from both the University of California San Francisco and Stanford. Sitting across from the late Dr. Tim Kelly, former UCSF intern selection director, I shared my advisor's comments. He laughed, then said, "Rebekah, you can go wherever you want." Months later, I matched at my first choice: Seattle Children's.
Many students do not have access to mentors who share their experience as a minority in medicine, who can help guide their way forward. Our group mentoring program seeks to fill that gap. In the middle of a pandemic, more than ever, mentorship matters.
Mentorship fosters a sense of community, a collective feeling of knowing that we're in this together. Research studies have demonstrated that the struggles along the path to medicine are inequitably placed on the shoulders of those from racially marginalized backgrounds. Educational inequality contributes to black and brown students being more likely to attend under-funded and poorly resourced schools that may lack the STEM Foundation to help them thrive in college.
In undergraduate education, UIM pre-medical students drop out of the "pre-med track" at higher rates than their peers. In a study of Stanford students expressing interest in medicine, almost 50% of UIM students dropped out of pre-med, compared with 17% of non-UIM students. Major factors contributing to this dropout rate include difficulty with chemistry courses and discouragement from undergraduate advisors.
Upon entering medical school, only 32% of white students have educational debt, compared with 55% of Native American students, 59% of black students, and 43% of Latinx students. Between academic challenges and the financial strain of undergraduate education, plus the thousands of dollars it takes to apply to schools, it should be no surprise that UIM students make up less than 12% of medical school graduates.
Once in medical school, the inequities continue. In a predictive model for the U.S. Medical Licensing Examination, a series of three web-based tests, black students were predicted to score 16 points lower on all three, representing more than three-fourths of a standard deviation. The University of Washington found that clinical grading on third-year rotations favored white students over UIM students. A study from 123 medical schools showed, when controlling for grades, test scores, and extracurricular activities, black students were still less likely to be elected to Alpha Omega Alpha, a prominent medical society that is viewed favorably during the residency application process. When Step 1 cutoff scores are used to grant residency interviews, black applicants are three to six times less likely to receive an interview.
These statistics demonstrate that at every major benchmark, UIM students are held back, not by their own performance, but by the persisting effects of structural racism. Each step is a hurdle. Privilege allows some to walk around hurdles like application expenses or pre-medical debt. Some are able to jump over hurdles, such as grading bias and standardized testing. Yet, the success of a few does not negate or justify the hurdles' existence. Mentoring is a way to coach UIM students to navigate structural barriers and avoid common pitfalls, but so much more can and should be done. By systematically removing the hurdles, how many more talented, passionate physicians would we have?
As COVID-19 continues to affect our daily lives, medical students worry about its impact on the application process. Our mentees wonder how they can demonstrate their ability to work at a large children's hospital without rotations or get a feel for a program without in-person interviews. Both the Association of American Medical Colleges (AAMC) and a few specialties, including pediatrics, have released guidance to residency programs for navigating the year ahead, including virtual clerkships for visiting students and remote interview days. This framework has provided immense clarity for students and those of us supporting them. I hope to see all specialties take similar steps to publicly share their approach.
As the application process becomes virtual, I worry about the impact that intangible qualities may have on a UIM applicant's success. Implicit bias testing reveals that many healthcare providers have low-to-moderate implicit bias against black and Latinx people, similar to the wider population. How does that thought process translate to seeing a UIM applicant on a computer screen? What implications would that bias have on their interview experience?
Residency programs need to incorporate structural racism training and discussions, including the studies referenced above, into their interview process so all applicants can receive equitable consideration. Dr. Christle Nwora, incoming medicine/pediatrics resident at Johns Hopkins, noted the need for consistent internet access and web cams for all applicants, as well as non-punitive plans to mediate mid-interview technical difficulties.
Reflecting on my own residency interview experience, I found it invaluable to walk through the hospital, to see a black resident on rounds or a black attending at a teaching conference. Seeing black hospital staff in the hallways or a black family in the waiting room all reassured me that I would not be alone there. While that walk-through experience may not be duplicated virtually, programs should recognize that visible diversity, from leadership to patient population, is important to UIM students, and make efforts to substitute that first-hand experience.
Finally, the recent passing of Ahmaud Arbery demonstrates the pressing questions that UIM students have about each city they consider: Am I safe here? Do I feel comfortable? Can I call this place home? These insights, which typically come from touring the hospital and city on the interview day, can be gleaned from conversations with other UIM students, residents, or faculty at the institution. The students in our program have already self-organized to create spreadsheets to share these personal, intangible perspectives. Residency programs should facilitate connections to provide these vital experiences.
The medical school class of 2021 has a unique year ahead. As a mentor, some of the greatest reassurance I can give to a mentee is telling them how I've been in their shoes. I can't this year, but our mentoring program's leadership and the team of pediatricians and residents we have recruited to serve as one-on-one mentors send a clear message that we are in this with them. The COVID-19 pandemic has revealed so many possibilities for connection and community that we never envisioned. Our mentoring model demonstrates the need for providing support for UIM students across institutions, where resources and diverse representation vary widely. It is only the beginning of our efforts, but we hope that by sharing our mission, other specialties will forge their own path.
Rebekah Fenton, MD, is a pediatrician and adolescent medicine fellow at Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago.