In Emergency Medicine, Promotion to Chief Resident Least Likely for Women of Color

Among emergency medicine residents, promotion to chief resident was less likely for those who identified as Black, and especially for women from underrepresented groups, compared with their white peers, according to a retrospective cohort study.

In fully adjusted models, women underrepresented in medicine (those who identified as Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander) were the least likely to be promoted to chief resident, and half as likely to be selected compared with white men (adjusted risk ratio [aRR] 0.50, 95% CI 0.06-0.66), reported Jennifer Tsai, MD, of the Yale School of Medicine in New Haven, Connecticut, and colleagues.

Moreover, Black residents of both sexes were 55% less likely than white residents to be promoted to chief resident (aRR 0.55, 95% CI 0.36-0.82), they wrote in JAMA Network Open.

Notably, white women were the most likely to be given this promotion and 20% more likely to be selected than white men (aRR 1.20, 95% CI 1.03-1.39).

“These findings confirm the importance of recognizing the double jeopardy of intersectional identities; the ways women who belong to minoritized racial and ethnic groups receive compounded, unique insults from axes of race as well as gender,” wrote Tsai and colleagues. “Their marginalization is not merely equivalent to the added effects of racism and sexism, but complicated and deepened by these intersecting identities, which cause unique problems not faced by white women or men of color.”

Through their recognition as leaders within residency programs, chief residents subsequently gain financial compensation, departmental influence, and opportunities for career advancement, Tsai and team said, but residency programs do not have standardized criteria to select chief residents.

In an invited commentary, Alden Landry, MD, MPH, of Harvard Medical School in Boston, and Italo Brown, MD, MPH, of Stanford University School of Medicine in California, noted that the role of chief resident “is often considered an unspoken metric for fellowship trainee positions, medical directorships, and other leadership-oriented roles.”

“Some consider facets such as individual popularity, likability, and on-shift performance to be driving forces in the selection process for chief residents,” they wrote. “Although the selection criteria are thought to be objective, there is an inherent subjectivity to nomination, ranking, and voting.”

Landry and Brown pointed out that chief residents often have close relationships and mentorships with faculty and administration, with some fellowship programs later selecting from a pool limited to chief residents, and some departments preferring to hire them. “The skill set development that chief residents undergo is attractive to employers and directly translates into administrative and leadership roles in EM [emergency medicine],” they added.

Ultimately, the disparities shown in this study could affect health outcomes for vulnerable populations, they argued, noting that there is evidence for “improved clinical outcomes, greater adherence, reduced utilization, and lower healthcare expenditures (all metrics of interest) when clinicians come from URIM [underrepresented in medicine] backgrounds.”

For this study, Tsai and colleagues analyzed data from the Association of American Medical Colleges and the Electronic Residency Application Service on emergency medicine residents in the graduating classes of 2017 and 2018. Non-U.S. citizens (who did not have race or ethnicity data available) and those with incomplete U.S. Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score data were excluded.

For their models, the researchers adjusted for race and ethnicity, sex, USMLE Step 2 Clinical Knowledge score, and program clustering.

In total, 3,408 residents were included; 66.1% were men, 69.5% were white, 13.2% were Asian, 7% were more than one race, 4.6% were Hispanic, and 4.2% were Black. Of chiefs, 63.4% were men, 74.3% were white, 11% were Asian, 2.3% were Black, and 3.5% were Hispanic.

In unadjusted models, Asian and Hispanic residents were less likely than their white peers to be named chief resident, but this finding was not significant in adjusted models.

Tsai and team noted that they were not able to stratify their findings to include more granular racial and ethnic groups, or within-group analyses. They were also unable to identify trans and nonbinary residents, who also face discrimination in medical training. They couldn’t capture residents who were offered a chief resident position and declined, or factors besides test scores that informed chief resident promotion.

The non-significant disparities for Asian and Hispanic residents could have been due to statistical underpowering, which the researchers called “a widely known issue within disparity studies: greater granularity of race, ethnicity, and gender variables is necessary for more accurate analysis, but stymied by foundational lack of diversity in the healthcare workforce.”