Inside Baseball-leveling the Playing Field in the Surgical Residency Selection Process

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September finds us in the heat of the pennant races around the country. Many well prepared teams who drafted well are leading their divisions; others are out of the race and divesting of assets presuming they will compete on another day. It is also the time when medical students interested in surgery approach the upcoming annual “MATCH ‘process with trepidation and excitement. Many will compete for precious interviews, many will succeed, some may not, and many will get an opportunity to pursue a life-long dream career in surgery “on their team of choice.” The rules of engagements in this residency game are often poorly defined for under-represented minorities aspiring to pursue surgical careers.
In this edition of the Annals of Surgery, Dr Aimee Gardner, PhD, outlines best practices in the selection of a more diverse physician cadre to help diversify surgical programs.1 By enhancing selection and admission criteria, Dr Gardner outlines the ideal means to address the lack of diversity in surgical specialties. A thoughtful assessment of the pipeline problem and her recommendations to enhance the selection of a more diverse surgical workforce are needed now more than ever.
These observations are not new to leadership in the surgical field. It has long been noted that diversity enhances representation and better serves those most affected by disparities, namely the underserved and underrepresented populations in our country.2 The broader benefits of diversity in medicine have been well-defined since 1978 when Justice Powell and the Supreme Court decision Regents of University of California v. Bakke suggested that holistic evaluation of applicants including the consideration of demographic characteristics, in addition to academic metrics, explaining that medical students “may bring to a professional school of medicine experiences, outlooks, and ideas that enrich the training of its student body and better equip its graduates to render with understanding their vital service to humanity.”3
Despite this landmark decision, many have observed that the current selection process in academic medicine and surgery is based upon narrowly defined metrics, such as the USMLE scores, medical student evaluations, letters of recommendation, and other “focused” criteria. This selection process has a distinct “inside baseball” feeling. Those who know and understand how to navigate the resident application process advance, excel, and ultimately rise to receive interview opportunities in the most highly sought after programs. Those who do not have inside connections or advocacy from “connected program leaders” are less likely to succeed and often do not receive preferred training positions.
A number of enlightened investigators have highlighted the limitations of testing for cognitive function (ie, USMLE scores) as inadequate to predict performance.4 This observation could certainly be extended to surgical residency. As well, the interview process is often not objective or inclusive of diverse thought from a wide perspective, and therefore it limits the potential for a diverse applicant pool to be successful. Many evaluators of resident applicants “pick one who looks or acts like me” and therefore limit the selection of diverse applicant pools. The solutions include a number of strategies to level the playing field, such as de-emphasizing USMLE metrics, biased medical student evaluations (honors in surgery core rotations), and letters of recommendation from “established” program leaders as potential solutions to diversifying the applicant pool. This includes the need to objectify personal statements and letters of reference, as well as to develop more inclusive interviewing teams.
The selection process should always emphasize academic excellence and potential as its foundation. However, a holistic approach to residency selection may also include evaluations of community engagement, leadership roles, unique personal attributes, and elements of diversity, which have heretofore rarely been considered as central to the process.
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