How Can Best Practices in Recruitment and Selection Improve Diversity in Surgery?

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Improving the representation of various demographics (ie, race, ethnicity, sex, age, religion, disability, sexual orientation, economic status) is receiving increasing interest within the surgical community, especially among recent reports that certain subgroups who join surgical training programs are less likely to complete training.1 Diversity is an important characteristic for any organization. For example, research indicates that team diversity plays a large role in the decisions teams make in high-stakes situations.2 Studies examining diversity in the workplace have also shown that for every 1% increase in sex or racial diversity, a company's revenue increases by 3% and 9%, respectively.3 Finally, diverse physicians and organizations better represent, and thus better serve, patient communities with diverse needs.
One of the solutions to ensuring a diverse workforce within surgery begins at the entry point—selection. Currently, the decision of who will become a surgeon belongs to residency programs. This screening process involves review of applicant United States Medical Licensing Exam (USMLE) scores, medical student performance evaluations, letters of recommendation, and personal statements. Those who have been identified as promising from this process are then invited to an on-site interview.
Unfortunately, the residency screening process has received criticism as a result of concerns that it lacks incremental validity, is unreliable, and inefficient.4,5 There are also 2 specific areas of concern with respect to diversity and inclusion efforts: The first is the use of screening tools. Traditional tests of general mental ability and tests of specific cognitive abilities (eg, numerical, verbal, or spatial ability) have raised concerns regarding fairness, since these types of tests can result in substantial racial differences in test performance, which are not matched in job performance.6 As such, the use of cognitive-based assessments, such as the USMLE, as a primary screening tool may be at odds with any efforts to enhance diversity.5
Another issue involves the predominance, and weight given to, evaluations from the interview process. Reviews have shown that the majority of on-site interviews in surgery are unstructured5 and include a disproportionate amount of inappropriate questions about applicant marital status, family plans, ethnicity, and religion.7 Unstructured interviews also have increased likelihood of interviewer subjectivity such as the “just like me” bias (i.e., an interviewer's propensity to favor candidates with similar looks and experiences to themselves). Thus, this screening method, which is given the most weight in making final rank decisions, likely limits potential to enhance diversity. By implementing unstructured interviews, decision makers may be creating a homogenous working environment of surgeons with similar profiles and personalities to their own.
The question arises, then, how can we modify our current selection system to support diversity efforts within surgery? As shown in Table 1, there are a number of evidence-based solutions. The first suggestion involves incorporating screening tools that level the playing field for all applicant groups. As noted earlier, cognitive-based tests that appear neutral can have a discriminatory effect on certain protected groups.6 The United Kingdom (UK) has recognized the discriminatory powers of typical cognitive-based tests, and has developed the UK Clinical Aptitude Test, which is being used as a primary screening tool and has been shown to predict performance in medical training and beyond, while also widening access to a wide range of demographic groups.8 Other screening tools, such as situational judgment tests, which confront applicants with descriptions of standardized realistic situations and ask them to select the most appropriate response, have also been shown to be as strong a predictor of performance as cognitive-based assessments, but without the discriminatory potential.
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