Advocating for Underrepresented Applicants to Psychiatry: Perspectives on Recruitment

The importance of a diverse physician workforce in improving population-based health outcomes has been described in numerous studies (1–3). These findings have promoted the development of recruitment frameworks in the United States (such as the identification of underrepresented minorities in the American Medical College Application Service) to encourage enrollment of diverse applicants in medical schools. Despite these efforts, little work has been done to explore the role of diversity-conscious recruitment at the level of residency education, resulting in a lack of organizational guidance in residency recruitment efforts (4). In psychiatry, racial disparities between the physician workforce and patient population suggest that the critical need to train psychiatrists with diverse backgrounds is being unmet (5, 6).

Here, we highlight the importance of diversity in residency training, explore potential barriers psychiatry residency programs face in recruiting underrepresented residents, and suggest various opportunities through which residents can advocate for diversity-conscious policies in their own residency programs.

Historical Perspectives on Diversity in Recruitment

Diversity-conscious recruiting in medical education began during the civil rights movement and resulted in the goal of the Association of American Medical Colleges (AAMC) to achieve 12% enrollment of underrepresented minority students in medical schools (7). The term "underrepresented in medicine" emerged in 2003 from the AAMC to describe "racial and ethnic populations that are underrepresented in medical professions relative to their numbers in the general population" (8).

In 2009, the Liaison Committee on Medical Education developed a set of diversity goals to urge programs to institute policies that would increase diversity in medical education programs (9). This extended beyond the traditional understanding of underrepresented in medicine to include diversity in gender, sexual orientation, physical or mental ability, and socioeconomic background.

Today, neither the Accreditation Council for Graduate Medical Education nor the American Association of Directors of Psychiatric Residency Training has developed diversity-conscious recruitment policies, leaving residency training programs to develop their own recruitment strategies.

Significant racial disparities between the psychiatric workforce and the general population persist. African Americans comprise approximately 6.6% of all psychiatry residents in the United States compared with a 13.12% representation in the general population, and Hispanics comprise roughly 8.3% of U.S. psychiatry residents compared with a 17.1% representation in the general population (5, 6).

Reduced recruitment of underrepresented physicians may adversely affect the quality and quantity of care for underserved populations (1, 2). Studies have found that patient-physician racial concordance results in greater perceived quality of care, increased receipt of preventive care, and higher satisfaction with overall health care among minority populations (3). The importance of patient-physician racial concordance can be partially explained by the neuroscience of prejudice. An interactive set of complex neural structures involving the amygdala has been linked to fear conditioning (10), and recent studies show that early exposure to diversity diminishes amygdala response and reduces the salience of race later in life (11). Perhaps diversity in psychiatry residency programs would not only promote better quality of care but also attenuate any implicit prejudice among psychiatry trainees.

Challenges and Disparities in Representation

Despite the advantages of diversity in residency programs, there are significant barriers in achieving diversity, including limited understanding of how underrepresented applicants select programs, a lack of existing diversity in psychiatric departments, and the perceived lack of diversity among faculty and staff. Identifying specific qualities that underrepresented applicants seek in residency is essential in recruitment, because it aids in understanding the barriers and in finding solutions. Unfortunately, data are limited regarding underrepresented psychiatry applicants and recruitment strategies among psychiatry residency programs.

Several studies of nonpsychiatric residency programs show that underrepresented applicants tend to favorably rank programs with greater gender and racial diversity (4, 12). Furthermore, programs with greater diversity may be perceived as being more committed to providing care for underserved communities and demographic groups, a feature that may be attractive to underrepresented applicants (4, 12). One study showed that underrepresented minority students were more likely than both Caucasian and nonunderrepresented minority students to show interest in providing care for the underserved (1). Conversely, in programs lacking diversity, underrepresented minority applicants may feel negatively stereotyped, less confident, and a decreased sense of belonging (12).

Although existing diversity in a program may be important, the perception of diversity may also be a significant barrier to consider. In a case study, the Diversity Recruitment Committee at the University of California, Los Angeles (UCLA) examined barriers in recruiting successful underrepresented-in-medicine applicants. Although the UCLA psychiatry program takes pride in its diverse residents and diverse patient population, the perception of this diversity was limited by lack of resident involvement with electives that offer care for underserved populations, lack of coordination with medical school diversity efforts, and limited interactions between existing underrepresented-in-medicine faculty and applicants (4).

Next Steps and Interventions

Although significant challenges in recruiting underrepresented applicants exist, residents can play a critical role during the recruitment process, because they often provide informal guidance for residency program leadership in recruitment programming. Additionally, residents’ awareness of the need to specifically recruit underrepresented applicants may promote changes in the recruiting activities of some programs. For example, in selection committees, one can advocate by speaking enthusiastically to a program director on behalf of underrepresented applicants. After interview day, programs can communicate directly with underrepresented applicants a sense of gratitude for visiting and an invitation to request more information.

Another potential avenue for change is to consider international medical graduate applicants during recruitment, a category of applicants who fill approximately 30% of general psychiatry residency positions and 50% of fellowship positions annually (6) and serve as a significant source of cultural and ethnic diversity. International medical graduates are the target of significant stigma in residency recruitment as a result of concerns related to limited American clinical experience and the impact on a program’s reputation if applicants deemed less competitive are accepted (13). Concerns about the quality of medical care provided by international medical graduates appear to be unfounded. A 2017 mortality analysis of older patients treated by internists in U.S. hospitals found that patients treated by international medical graduates had slightly lower mortality rates after adjusting for patient and physician characteristics and fixed hospital effects (14). Furthermore, according to the American Psychiatric Association, international medical graduates play a critical role in caring for underserved populations in the United States: they generally receive a higher proportion of their income from Medicare and Medicaid, have been shown to work longer hours in the public sector, and more frequently treat patients with psychotic disorders (15). Thus, increased recruitment of international medical graduates achieves two important outcomes: enriching the diversity of training programs and caring for underserved patient populations.

Finally, resident involvement with program diversity committees, participation in outreach efforts with medical student interest groups, and interest in underrepresented medical student rotators are interactions that can lead to an inclusive atmosphere within an academic environment. Although residents may have less influence on the culture of an institution as a whole, the culture of an individual program is directly dictated by those working in it. By explicitly advocating for diversity-conscious recruitment and applicant selection, residents can shape program values and priorities to provide fertile ground for underrepresented applicants to flourish.

Conclusions

Projected changes in the demography of the United States suggest a need for an increasingly diverse physician workforce. The successful deployment of diversity-conscious recruitment programs for medical school admissions provides promise that similar efforts can be made in residency recruitment processes. Initial, but limited, interventions in this setting provide some evidence that an emphasis on recruiting diverse residents can have a meaningful impact. Psychiatry residents are key stakeholders to advocate for diversity-conscious recruitment, promote a culture of valuing residents from diverse backgrounds, and highlighting the need for, and importance of, interventions specific to diversity-conscious recruitment within individual programs.

Key Points/Clinical Pearls