We may all bleed red but that doesn’t mean there isn’t still diversity across communities—from genes to environments to culture—many factors impact our healthcare experiences. With hiring committees overlooking residents from under-repped communities, Black and Hispanic doctors are still being shut out of top jobs.
In 2020, medical illustrator, Chidiebere Ibe, brought a spotlight to how important diverse representation is in the medical field by creating the first medical illustration of a Black fetus, sparking a conversation on how vital it is that providers reflect the communities they work with.
Adopting an intersectional approach is one tool that can help us achieve that. Intersectionality is more than just a buzzword; it is a legitimate academic concept and an important lens to conduct research through.
Taking this cue, a 2024 paper published by JAMA found that the relative ratio of chief resident promotions was reduced for residents who identified as Asian or Black, but particularly for women in traditionally under-represented communities, compared to their White counterparts.
Study found disparities are most severe among Black residents and URIM women
The authors found that promotions to Emergency Medicine Chief Resident were lowest among physicians who self-identified as Asian or Black, particularly for women described as under-represented in medicine (URIM); the authors define URIM as Black, Hispanic, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander residents).
Of the 3408 residents included in the study, most (69.5%) were White men. Approximately 21% of the 3408 residents were promoted to chief residents, and of those, 63.4% were men.
When stratified by race, most chief residents were White (74.3%), then Asian (11%), then Hispanic (3.5%), and then Black (2.3%). In the unadjusted model, White residents were significantly more likely to be chosen as chief resident while Black residents were the least likely to be chosen.
In the adjusted model—accounting for race and ethnicity, sex, USMLE Step 2 scores, and residency program—a significant sex disparity that favored women (aRR=1.14) was observed. However, racial and ethnic disparities for Black residents remained significant, with Black residents only half as likely (aRR=0.55) to be promoted.
When accounting for both sex and race, White women residents were more likely to be selected for chief resident compared to White male residents. White male residents were more likely to be selected compared to males from the other groups. There was no significant difference between Asian male residents, URIM male residents, and Asian female residents. The group with the lowest likelihood of being selected for chief resident was the URIM women.
The study was done on a national cohort of emergency medicine residents
The researchers conducted a retrospective study of 3408 EM residents who graduated in the years 2017 and 2018 using the Association of American Medical College’s data services. They categorized ethnicity as:
- White
- Asian
- Underrepresented in medicine (URIM) – Black, Hispanic, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander
The study did not specify which particular communities are represented in the “Asian” sub-group (which is a tad ironic for a paper focusing on the benefits of intersectional research). Asia is a large geographic area including many different ethnicities.
Hospitals must review their current hiring practices
The study highlights why it’s important to consider intersectionality when creating HR policies to combat implicit sexist or racist biases. If the authors had only considered the increased likelihood of White women being promoted, they might have incorrectly downplayed sexism to focus on racism, but that would negate the experience of URIM women. Similarly, if they looked solely at sex, they may have negated the experience of the Black community, both men and women. Applying broad brush changes could end up reinforcing inequitable policies.
The data from this study suggests that it might be wise to review the chief resident selection process by residency programs and accreditation bodies to ensure workforce equity for promotion and opportunities for leadership. These processes must consciously aim to better strike a balance between addressing inequities for whole groups (e.g., women in medicine) with intersectional identities (e.g., American Indian women in medicine).
There is more work to be done
The study was not able to include more granular racial and ethnic groups, nor were they able to identify trans and non-binary residents. The researchers also did not have the data to account for individuals who may have been offered a promotion but declined.
There are also limitations in statistics, including the number of covariates that can be included in any given study; however, the study remains (as of October 2024), the largest one to examine racial and gender disparities in chief resident selection for EM residents.
There are no systematically defined criteria for chief resident selection
Despite the significant impact of a promotion to chief resident, there is not only no standardized criteria for the selection process, but also very little national data on how race, ethnicity, or sex can affect it.
With already existing racial inequities in the healthcare space, this lack of data does a disservice to the many healthcare workers from minority communities whose career growth and financial compensation are affected, leading to higher rates of depression and burnout.
The authors suggest their research builds on a current discussion about the sources of racial inequities in medical education and how they threaten a sense of belonging for certain communities with training programs.
With prior research showing that that trainees of color are almost 30% more likely to withdraw from residency, and 8 times more likely to take a leave of absence for performance difficulties, this has far reaching, real-life consequences.
Race and sex are often included as demographic data, potential confounding factors, or independent variables in their own right, but the real world is more complicated—and while no single study can replicate all of those complexities—an intersectional approach in hospital HR departments could go a long way in addressing some of these professional inequities.
Reference
- Tsai JW, Nguyen M, Dudgeon SN, et al. Race and Sex Disparities Among Emergency Medicine Chief Residents. JAMA Netw Open. 2024;7(9):e2432679. doi:10.1001/jamanetworkopen.2024.32679
