Success in Increasing Diversity: One Residency Program's Journey

Given the low rates of under-represented minority (URM) residents[1] and practicing physicians[2] in ophthalmology, ophthalmology training programs in the United States have been charged with increasing diversity to better represent our population. There have been great efforts from the Association of University Professors of Ophthalmology and the American Academy of Ophthalmology to expand the pipeline, particularly through the Minority Ophthalmology Mentoring program.[3] Other groups such as the Rabb Venable Research Foundation and the Student National Medical Association have also been crucial in encouraging and supporting URM students. Initiatives such as the Einstein Enrichment Program for 7th to12th graders and the Diversity Student Summer Research Opportunity Program for college juniors and seniors at our institution work to encourage URM students to go into medicine and biomedical sciences at an earlier stage. However, once URM students are in the pipeline as potential future ophthalmologists, they may encounter barriers in the admissions process based on traditional metrics such as United States Medical Licensing Examination (USMLE) step scores and selection into Alpha Omega Alpha.[4] We believe it is the responsibility of residency program leadership to conduct the admission process with an eye toward matching qualified URM students. In our program at Montefiore Medical Center/Albert Einstein College of Medicine, we have successfully increased representation in our residency program. We would like to share our process as a potential model for this endeavor.

In the January 2018 match, the SF Match (San Francisco, CA) began allowing an optional notation by students as to whether they came from an under-represented background. Starting the following match cycle, we began a holistic review of applications from URM students, which has been demonstrated to result in more diverse classes by Einstein's medical school admission team.[5] As defined by the Association of American Medical Colleges, “holistic review refers to mission-aligned admissions or selection processes that take into consideration applicants' experiences, attributes, and academic metrics as well as the value an applicant would contribute to learning, practice, and teaching. Holistic Review allows admission committees to consider the “whole” applicant, rather than disproportionately focusing on any one factor.”[6] On a practical level for our program, this means that every application from a URM applicant is read in its totality, including scores, grades, personal statements, and letters of recommendation. All scores and grades are checked to meet basic criteria for predicted success in residency, typically meaning that the student did not need to repeat any course work, had a USMLE step 1 score above or close to the national average (approximately 230 for the years when step 1 scores were available), and was at least in the top two-thirds of their medical school class. The Medical Student Performance Evaluation was reviewed to make sure there was no professionalism issue or need for remediation. Letters of recommendation were reviewed to assure there were no concerns from advisors and mentors. Personal statements and letters of recommendation were read for insight into the students' journeys, and factors such as “distance traveled” were considered. In addition, at our program, we serve a predominantly black and Hispanic community in the poorest county in our state, where our patients and neighbors have many significant health issues. Thus, when reviewing applications, we appreciate a commitment to serving the underserved, whether that is through volunteer work, prior employment, or lived experience. We are typically able to identify evidence of this commitment in the applications of our URM applicants, in addition to many of our non-URM applicants. A final consideration for being granted an interview is having been born or raised in the Bronx or having spent significant time here during their formative years.

In the initial years of our holistic reviews, we were able to match 2 URM students in a class of 5 and 1 URM student in the following class of 5. In 2020, with the change to virtual interviews, we adjusted our screening process from having multiple people each read one-quarter to one-fifth of the entire pool to the program director (PD) and associate PD (APD) reading all applications, each reviewing half of the applications completely as well as confirming the applicants selected by the other director. We decided to limit application review to the PD and APD to avoid the possibility of different criteria being used for review by different readers. As described above, the majority of our applicants have excellent credentials, so we do not have a problem with unqualified applicants being selected for interviews and have not had any issues with acceptance of the applicants from the other members of the interviewing committee. From 2020 on, every application from a URM student was reviewed in a holistic manner by the PD or APD. A detailed outline of our procedure for reviewing applications from URM students can be found in [Table 1], we followed the same process in 2021.

Table 1 Outline of application review procedures

1	Use SF Match filters to sort for all candidates who indicated they are under-represented minorities
2	These applications are reviewed first, with a plan to dedicate approximately one-third of interview spots to URM candidates
3	Read through each application without any other filters, including standardized test scores, tier of medical school, or class rank—qualitative assessment of candidate, with consideration given to “distance traveled” (time spent approximately 5 minutes per application).
4	Invite 20–25% of the URM applicant pool to interview, compared with under 10% of the non-URM applicant pool

Abbreviations: URM, under-represented minority.

It is important to note that the large numbers of applications to ophthalmology programs make a holistic review of every application very difficult and time-consuming, which means it is very easy to overlook excellent applicants. Each year, like other programs, we receive approximately 600 applications and interview approximately 60 medical students, which means each student has on average a 1 in 10 chance of being interviewed at our program. With this ratio, many outstanding students are not granted interviews, usually only because we do not have room on our interview schedule and not because of any deficiency in their applications. Because only a small portion of the overall applicant pool is URM students, a lack of consideration for URM status would lead to low rates of interviewed URM students and thus low rates of matched URM residents. By considering these applicants separately from the general pool, we are able to increase our numbers without sacrificing quality of the applications.

This effort to invite more URM candidates led to a much higher number of highly qualified URM applicants on our interview list, with 20 of 63 interviewed applicants in 2020 and 19 of 62 interviewed applicants in 2021 self-identifying as URM. Having many URM students on our lists gave us the opportunity to rank URM applicants at the top positions on our rank list. We carefully reviewed URM status as we determined our rank order, noting that in 2020, 4 of the top 10 and 5 of the top 20 spots were URM students. From that rank list, we eventually matched two URM students for our five positions. In 2021, 5 of our top 10 and 9 of our top 20 spots were URM students, and we again matched 2 URM students for our 5 positions in the most recent match.

Our URM residents have thrived. While it is too soon to have Board of Ophthalmology Exam passage rates, we can report that two of our URM residents from the first year of our initiative were selected as our two chief residents for their final year. One of these residents was awarded “House Officer of the Year” from our entire institution and was also granted a prestigious Heed Fellowship for next year.

We believe that our success in matching URM students and increasing diversity is building on itself. The reputation of the program and its culture becomes actionable knowledge which circulates among future applicants. This in turns attracts more URM students, especially from more competitive upper-tier medical schools. Due to our concentrated efforts in this area, as of July 2022 ([Fig. 1]), our percentage of black ophthalmology residents will be much higher than the overall U.S. ophthalmology residency program percentage,[2] falling between the population percentage in the Bronx where we are located and the overall U.S. population based on U.S. Census data.[7] We will also be above the national ophthalmology average for Latinx residents[2]; efforts are ongoing to bring that number closer to representing our Bronx community. We will have fewer non-Hispanic white residents than the U.S. ophthalmology program average,[2] falling between the Bronx and U.S. population percentages.[7] We will also have fewer Asian residents than the U.S. ophthalmology program average,[2] although still above both the Bronx and U.S. population percentages.[7] In the 4 years prior to July 2022, we had zero black residents and 5% Latinx residents. We are pleased that our efforts have built on the long focus on diversity of our medical school and look forward to continuing to build on our success with our future classes. We hope that over time, the increased numbers of URM residents who become practicing ophthalmologists will eventually also lead to diversity in leadership in our field; yet another issue to tackle.[8]

Fig. 1 The comparison of race/ethnicity at Montefiore/Einstein ophthalmology program, all U.S. ophthalmology programs, and the U.S. and Bronx populations.

Publication History

Received: 27 April 2023

Accepted: 10 August 2023

Article published online:
05 September 2023

• References

• 1 Aguwa UT, Aguwa CJ, Onor GI. et al. Racial and ethnic diversity within U.S. residencies: trends from 2011 to 2019. J Surg Educ 2022; 79 (03) 587-594
• 2 Xierali IM, Nivet MA, Wilson MR. Current and future status of diversity in ophthalmologist workforce. JAMA Ophthalmol 2016; 134 (09) 1016-1023
• 3 Minority Ophthalmology Mentoring 2020 Annual Report: Cultivating the next generation. American Academy of Ophthalmology, Association of University Professors of Ophthalmology. Accessed March 03, 2022 at: https://www.aao.org/Assets/f68527f8-3eb9-402f-9515- 2f703514bcdd/637618869759630000/minority-ophthalmology-mentoring-program2020-annual-report-pdf?inline=1
• 4 Knight OJ, Mike EV, Elam AR. Beyond implicit bias to explicit action. JAMA Ophthalmol 2021; 139 (12) 1283-1284
• 5 Kerrigan N, Akabas MH, Betzler TF. et al. Implementing competency based admissions at the Albert Einstein College of Medicine. Med Educ Online 2016; 21: 30000
• 6 Association of American Medical Colleges. Holistic review. Accessed July 23, 2023 at: https://www.aamc.org/services/member-capacity-building/holistic-review#publications
• 7 US Census Bureau. Quick facts. Accessed February 24, 2022 at: https://www.census.gov/quickfacts/fact/table/US/PST045221
• 8 Association of American Medical Colleges. U.S. medical school faculty by gender, race/ethnicity, rank, and department. 2020 Accessed March 03, 2022 at: https://www.aamc.org/media/8901/download