Authors: Liza Smith, MD, Ronnie Ren, MD, Melanie Camejo, MD, Caitlin Schrepel, MD and Alexis Pelletier-Bui MD on behalf of the CORD-Advising Students Committee in Emergency Medicine (ASC-EM)

This application guide is intended for Emergency Medicine bound medical students who identify as being from a group which is underrepresented in the medical field as well as their respective advisers and mentors. This guide is intended as a supplement to the General EM Applying Guide.

Background & Overview

Promotion of diversity and inclusion in the healthcare workforce has long been a focus of many national healthcare organizations, including its incorporation as part of the strategic plan of the American College of Emergency Physicians (ACEP)(1). Despite this focus, groups traditionally considered to be Underrepresented Minorities (URM), including Black, Hispanic, and Native American doctors, remain underrepresented in their respective proportions among EM trainees (2).  This under-representation presents unique challenges for applicants to Emergency Medicine (EM) who identify within underrepresented groups.

As of 2004, the most recent year the Association of American Medical Colleges (AAMC) updated their definition of which persons were underrepresented in medicine, the definition is as follows:

“Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”(3)

While more inclusive than previous iterations, this definition does not adequately delineate all groups that more modern thinking would consider underrepresented. Individual institutions often have their own definitions inclusive of other groups of students, such as those who identify as Lesbian, Gay, Bisexual, Transgender, Queer, and others (LGBTQ+), those who have physical disabilities, or those who are from lower socioeconomic status. These groups have yet to be widely included in definitions of underrepresented on a national level, however.  As such, these groups are under-recognized and are often not included in data collection regarding underrepresented persons, so there is very limited information on the state of these populations within medicine in general and within EM specifically. This addendum to the general EM applying guide aims to address all those who are underrepresented, whether it be a group specifically listed in this guide or not.

Being an Underrepresented Minority (URM) in medicine should be a point of pride, especially when getting into medical school alone is an incredible achievement only a small percentage of America can claim.  We recognize that some who read this guide may feel less optimistic about their identity or trusting of their environment, and it is these students we most want to reach. While the journey of medical school and residency application may seem like an “uphill” battle made even more challenging by your URM status, know that there are many resources out there for you.

What are the Challenges Facing Underrepresented Applicants?

One challenge facing URMs is overcoming the stigma that may come with being perceived as “different” in some way.  This difference may be embraced by some, but others may try to minimize it for a variety of reasons. There is a fine balance between being proud of your heritage/embracing your uniqueness and trying to blend in with your medical school class. Finding the right balance is different for everyone.  With this said, at the end of the day, we all wish to be considered on our merits and treated as equals.    

Another challenge is that application reviewers are human, and therefore prone to bias, often on a subconscious, or implicit level.  Overt discrimination based on race, gender, religion, sexual orientation, etc. is unacceptable in the selection process, but it remains an unfortunate fact that URM’s may face implicit discrimination when subconscious beliefs or unrecognized stereotypes result in unconscious reactions by reviewers.   In one study, EM residency applicants who self-identified as underrepresented completed a survey regarding factors that were important to them in selecting a residency program as well as data about their application.  This study found that while the median number of applications between underrepresented applicants (URMs) and non-underrepresented applicants (non-URMs) was similar, the median number of interviews was significantly higher for the non-URM group–20 interviews versus 15 interviews for the URMs (4).  The study did not differentiate between interviews offered or interviews attended, so there could be other factors, such as the socioeconomic challenges of attending many interviews, influencing these data (4).  

To address this, ACEP has supported implicit bias training for all EM providers (5). The Implicit Association Test (IAT) is one tool used within medical education to assess subconscious associations of particular groups with certain positive and negative characteristics.  In one study, a medical school administered the IAT to its admissions committee and found that both the faculty and student committee members had an unconscious preference for white applicants (6). By becoming aware of one’s implicit biases, one can consciously find ways to overcome them, and many programs are actively looking to bring more diversity into their residency classes as well as to their faculty at all levels.   While this may seem discouraging, there is growing awareness and focus on implicit bias within medicine which will hopefully, over time, mitigate these inequalities.

Maximizing Your Application

The majority of the application of an URM student should not differ from that of a non-URM student. Factors such as supportive SLOEs, good clinical rotation grades, strong board scores, extracurricular activities, and leadership roles should still be the emphasis of the application.  

Preclinical Years

Medical school demands can feel overwhelming, even worse if you feel isolated.  Please know that you are not alone. Find your support network of family, friends, and mentors who can support you throughout this journey.  Stay close to your loved ones. Being a URM in medicine may mean being the first physician in your family or group of friends. They may not know how to properly support you in medicine yet, but they also know you best. Remember that this is new to them as well. Work with them to foster understanding and support. Learn to take care of yourself in order to better care for others. Some may benefit from school resources for wellness and mental health support.  Others may have to seek out mentorship or resources from other institutions. Looking for help is not a sign of weakness, but a measure of self-awareness and an important part of becoming a better physician.

Find a good mentor. The majority of URM physician leaders credit at least a part of their success to mentors who helped them grow, establish networks, and unlock opportunities to advance their careers. Every student, including URM students, are advised to seek out advisors and mentors to help guide them through the complicated process of advancing in both medicine and life – a path full of cultural nuances that may come naturally to traditional students but are often taken for granted.

An adviser or mentor with similar URM background and understanding of your specific needs as an EM bound applicant is of course helpful. They can offer perspective in ways non-URM advisers often cannot. This can be logistically challenging for many students, however. Worse, pigeonholing oneself to a mentor based solely on their minority background – by choice or by well-intentioned encouragement – may backfire if they are not equipped to advise you on EM specific issues.  You may find yourself seeking out more than one mentor, each one bringing his or her own expertise and perspective to your experience. Utilize diversity groups within EM and other medical associations for URMs that may have resources to identify mentors that meet your needs (see list of resources at the end of this guide).

Having any mentor in EM, as long as both parties are committed, is better than having none.  Good expectation setting and meaningful conversations may overcome initial differences, creating a mutually enriching relationship.  At a minimum, these mentors can explain the universal expectations for matching in emergency medicine, even if that path might not be equitable yet. Understanding the importance of role models and mentorship in the recruitment and advancement of underrepresented applicants, many programs are seeking out ways to recruit and retain faculty at all levels from traditionally underrepresented minority groups.  

There are additional opportunities specifically for Underrepresented Minority students during the preclinical years.  Many institutions offer diversity summer fellowships (like this one) which take place between first and second year of medical school in addition to some more longitudinal projects for URM students.  Although these programs are sponsored through many different organizations and institutions, PENN has compiled a good representative list here.  If this is something you are interested in, it is worth doing your own search to see what additional opportunities are out there as this list is by no means comprehensive.  

EM Rotations

There are many factors that go into choosing where to complete an away rotation in EM–trying out a new geographic area, a different type of clinical setting, a different patient population, etc.  Know that many programs are committed to fostering inclusive learning environments and are eager to increase the diversity of their residency classes. One of the ways programs have sought to recruit underrepresented applicants is through Visiting Elective Clerkships for students from groups underrepresented in medicine.  These electives often offer a stipend to offset the cost of rotating at an away institution and are often focused on caring for underserved populations or on decreasing health disparities. A listing of these opportunities can be found through the Society for Academic Emergency Medicine (SAEM) or through the Emergency Medicine Residents Association (EMRA).

Electronic Residency Application Service (ERAS)

ERAS includes the curriculum vitae section of your application which shows the education, work, extracurricular, leadership, and volunteer experiences you have completed up to this point.  ERAS asks applicants to upload a photograph of themselves which will be visible on the front page of the application. Including a photograph is optional, but is almost universally expected.  There have been discussions in other specialties about removing the photograph from the ERAS application or making photographs available only after an applicant has been offered an interview as a way to counter implicit bias (7).  However, this idea has not garnered wide acceptance.  One can also question how a program’s ability to view an applicant’s Standardized Video Interview would fit into this semi-blinded scenario.  

In regards to the rest of the ERAS application, one must keep in mind that for some applicants, their URM status is not so clearly discerned from a name or a picture for instance.  For these applicants, you or your advisors may question whether or not to include certain aspects of your previous experiences if they highlight or bring attention to your URM status.  For example, many LGBTQ+ applicants are concerned about “outing” themselves in their application if their previous work, volunteer, and extracurricular experience is strongly associated with LGBTQ+ organizations or causes, as this may open them up to implicit or explicit bias from application reviewers. In a 2015 study, 43.5% of medical students who concealed their sexual identity in medical school stated they did so because they feared discrimination (8).   Speaking on behalf of EM advisors and educators, we feel that all of you should be proud of all the work that you have done and, in general, should not hesitate to include it on your application.  Ideally, you want a program where you feel comfortable being yourself, but if you are uneasy about this decision, it can be helpful to discuss your concerns with your mentor.

Some applicants whose URM status may not be readily apparent may face constraints outside of their control necessitating seeking out a match in a geographic region, for instance, where they may not feel a connection or comfort with their URM status being well received, such as those pursuing a military match or who are likely to be less-competitive.  An argument can be made for these applicants to be fully themselves and trust in the progress that has been made when it comes to overcoming implicit bias among reviewers. Some applicants or their advisors may feel that the best course of action for them is to limit how much of their URM status they reveal in the initial application. It is also important to acknowledge that there may be occasions when an advisor or a dean may recommend excluding certain portions of your application in the name of preventing bias from reviewers.  It can be intimidating to go against the advice of someone in a position of power, and it may shake your confidence in an already stressful application process. This judgement is a very personal one and a decision that an advisor within the URM community might be best suited to help guide. Ultimately, limiting the amount of information on your application concerning your URM status is a very personal decision that can only be made by you. You should put forward the version of yourself that you are most confident and comfortable being.

Personal Statement

A personal statement is by definition personal, but some URM applicants may worry about revealing too much and once again opening themselves up to implicit bias among reviewers.  You will want to write about personal experiences that mean something to you, revealing as much of yourself as you are comfortable with. If you would like to share what it was like being the first doctor in your family or make reference to your same-sex partner, you are free to do so.  If you have hesitation about including these topics, then don’t. Know that of all the components of your residency application, the personal statement carries less weight than almost every other part, so don’t spend too much time angsting over it.

Program Selection

Just as there are many factors that go into choosing an away rotation, there are even more that go into selecting the program where you will complete residency training.  Try to choose a location where you will be happy spending the next three or four years of your life. Residency can be even more demanding than medical school, and having a strong support network can be even more critical.  This may mean pursuing programs that are close to family and friends or one that has other URM members or serves a community where you feel a connection.

Looking through a program’s current residency classes and faculty may help an applicant identify programs that are likely to provide easier access to opportunities for mentorship within the underrepresented community.  Also, speaking with current residents and faculty is an excellent way to gather information on the diversity of a program and its commitment to inclusion. Programs may have diversity statements formalizing their commitment to diversity, equity, and inclusion as part of their website or application information.  There is no efficient way to identify programs who offer these statements or a streamlined approach to locate these statements on the program’s website, however.

While some programs may not on the surface seem diverse, it is often not for the lack of effort, and they may have robust strategies for providing support and opportunities to URMs.  Developing diversity takes time and is made more difficult by the fact that other programs with already established diversity may be more attractive to an URM applicant. URM students who want to help shape or reshape the culture of a program, however, may thrive in these settings.  Feeling a connection on interview day is one of the most important factors in program selection, and this non-quantifiable “gut” feeling should probably outweigh any of the other more measurable considerations.

For married applicants, or those who have or plan to have a family, finding a location where your significant other and/or children will thrive is also important.  Speaking with faculty and residents on interview day or at the pre-interview social events can be a great way to get insight and information on this. Websites such as the US Department of Education site can provide helpful data as well.  It is also important to mention that while marriage equality is law in all 50 states, there is much more nuance regarding acceptance and legal recognition of same sex adoptive parents or insurance coverage for assisted reproduction.  Resources such as the Equality Map through the Movement Advancement Project can help students navigate through some of these legal subtleties.

Interviews

A general rule of thumb is to just be yourself during the interview day. This is a time to see if you “click” with the program and the people that you are interviewing with.  Be aware that any topic on your application can be brought up as a discussion point, so be ready to confidently talk about all aspects of your application. While no applicant should unwillingly endure personal questions about their race, religion, sexual orientation, etc – and these topics are technically “illegal” unless mentioned in your application – you should be ready to address these subjects if they were to arise.  However well-meaning the interviewer might be, these conversations are potentially awkward and may contain uncomfortable or even insulting questions. If you are uncomfortable with the direction of the interview or with answering a particular question, explain that to the interviewer and then move on to discussing something else. Interview day is supposed to be an exciting day. Highlight your achievements by putting forward your most accomplished and confident self.

On the other hand, you may elect to deliberately discuss these topics at the interview or more informally at the interview-associated social events. This creates an opportunity to gauge the response and gives you a chance to explore a program’s inclusiveness and support for diversity. Given that most interviewers are at least aware of illegal topics and will try to avoid asking, you as an interviewee have a great opportunity to control the narrative on this subject. It may benefit you to discuss with a mentor how to appropriately and most effectively do so.

What are some tools and resources that can help me? (9)

EMRA:  Many resources available through the Diversity and Inclusion Committee, which aims to “promote and support diversity and inclusion for medical students and EM physicians-in-training on the basis of gender, race, ethnicity, sexual identity, sexual orientation, age, socioeconomic status, religion, culture, disability, spirituality, and other characteristics; through education, collaboration, advocacy and research.”

SNMA: Formed in 1964, the Student National Medical Association is “committed to supporting current and future underrepresented minority medical students, addressing the needs of underserved communities, and increasing the number of clinically excellent, culturally competent and socially conscious physicians.”

AMSA-REACH: The American Medical Student Association’s Race, Ethnicity, and Culture in Health Action Committee has a tremendous list of resources available for students looking to get more involved.

AMA-MAS: The American Medical Association-Minority Affairs Section is free for all students, regardless of AMA membership and offers many scholarship programs and awards.

SAEM-ADIEM: The Society for Academic Emergency Medicine’s Academy for Diversity and Inclusion in Emergency Medicine is an excellent place to find an EM mentor.

There are multiple other organizations for support of medical students from underrepresented groups including, but not limited to:

Latino Medical Student Association (LMSA)

Gay and Lesbian Medical Association (GLMA)

Muslim Medical Student Association (MMSA)

Key Points

1. There are many resources to help Underrepresented Minorities find a support system, including mentors and advisors, to successfully navigate medical school and the residency application process.
2. Your EM residency application should reflect the person you are most comfortable being–highlighting the most accomplished, confident version of yourself.
3. In rare scenarios, an applicant may be advised or decide to limit or omit information relating to their underrepresented status in order to prevent implicit bias from application reviewers.

References

1. Parker RB, Stack SJ, Schneider SM; ACEP Diversity Summit 2016 Attendees. Why Diversity and Inclusion Are Critical to the American College of Emergency Physicians’ Future Success. Ann Emerg Med. 2017 Jun;69(6):714-717.
2. Association of American Medical Colleges. Electronic Residency Application Service Overview. 2017. (Accessed October 1st at https://www.aamc.org/download/358770/data/emergencymed.pdf)
3. Association of American Medical Colleges. Underrepresented in Medicine Definition. (Accessed October 1st at https://www.aamc.org/initiatives/urm/)
4. Boatright D, Simon J, Jarou Z, Tunson J, Flores S, Woods C, Heron S, Gisondi MA,  Druck J. 167 Factors Important to Underrepresented Minority Applicants when Selecting an Emergency Medicine Residency Program. 2015; 66 (4): S59–S60.  
5. Parker R, Stack S, Schneider S. Why Diversity and Inclusion Are Critical to the American College of Emergency Physicians’ Future Success. Ann Emerg Med. June 2017;69(6):714-717.
6. Capers Q, Clinchot D, McDougle L, Greenwald AG. Implicit Racial Bias in Medical School Admissions. Acad Med. March 2017;92(3):365-369.
7. Kogan, Monica and Rachel M. Frank. A Picture Is Worth a Thousand Words: Unconscious Bias in the Residency Application Process? The American Journal of Orthopedics. September 2015:E358-59.
8. Mansh M, White W, Gee-Tong L, Lunn M, Mitchell R, Obedin-Maliver J, Stewar L, Goldsmith E, Brenman S, Tran E, Wells M, Fetterman D, Garcia G. Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: “In the Closet” in Medical School. Acad Med. May 2015;90(5):634-44.
9. Jarou Z, Jeffrey D. Diversifying Emergency Medicine. EM Resident. 1/30/2016. (Accessed September 12th at https://www.emra.org/emresident/article/diversifying-emergency-medicine/).