A, The percentage of UIM trainees for internal medicine residents and subspecialty fellows, with all subspecialties combined. B, The percentage of UIM subspecialty fellows by subspecialty. C, The percentage of UIM trainees in internal medicine residencies and subspecialty fellowships in 2018. The horizontal line indicates the percentage of UIM trainees in internal medicine residencies. H/O indicates hematology/oncology; ID, infectious diseases; GI, gastroenterology; and PCCM, pulmonary/critical care medicine.
aP < .001.
eAppendix. List of Data Sources
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Santhosh L, Babik JM. Trends in Racial and Ethnic Diversity in Internal Medicine Subspecialty Fellowships From 2006 to 2018. JAMA Netw Open. 2020;3(2):e1920482. doi:10.1001/jamanetworkopen.2019.20482
Workforce diversity has been increasingly emphasized in academic medicine, especially regarding recruitment and retention of physicians underrepresented in medicine (UIM).1 In 2019, Stone et al2 examined gender in internal medicine (IM) subspecialty fellowships and showed substantial differences between subspecialties. However, the racial and ethnic diversity of IM residents and subspecialty fellows has not been described, to our knowledge.
We performed a cross-sectional study of race/ethnicity in IM residents and subspecialty fellows using published Graduate Medical Education census reports from 2006, when race/ethnicity data were first included, to 2018 (eAppendix in the Supplement). The University of California, San Francisco, institutional review board does not require approval for research using publicly available, deidentified data. This report follows Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.
We manually extracted and validated data for IM residents and fellows in the 9 following IM subspecialties: cardiology, endocrinology, gastroenterology, geriatrics, infectious diseases, hematology/oncology, nephrology, pulmonary/critical care medicine, and rheumatology. Allergy/immunology and hospice/palliative medicine were excluded because they are not restricted to IM trainees.
The Association of American Medical Colleges defines UIM as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population,”3 and the Association of American Medical Colleges Medical Minority Applicant Registry further describes UIM as individuals who self-identify as African American or black, Hispanic or Latino, American Indian or Alaska Native, or Native Hawaiian or Pacific Islander.4 Trainees whose race/ethnicity was reported as multiracial or other/unknown were not considered UIM. We obtained US population data for 2018 from the US Census Bureau.5
To determine whether there was a significant change in proportions during the study period, we performed the χ2 test for trend (Cochran-Armitage test) using Prism version 8.3.0 (GraphPad Software); results were considered statistically significant at a 2-tailed P < .05.
A total of 298 820 IM residents and 124 382 subspecialty fellows were included in our sample; 2184 residents (0.7%) and 1001 fellows (0.8%) who identified as multiracial and 42 377 residents (14.2%) and 8222 fellows (6.6%) whose race/ethnicity was other or unknown were excluded. Between 2006 and 2018, the annual number of IM residents and subspecialty fellows increased (from 21 855 to 26 228 residents and 8144 to 10 578 fellows) (Table). Over time, the percentage of UIM trainees was unchanged in IM residencies (2688 [12.3%; 95% CI, 11.9%-12.7%] to 3599 [13.7%; 95% CI, 13.3%-14.1%]; P = .28) but increased in all subspecialty fellowships (874 [10.7%; 95% CI, 10.1%-11.4%] to 1299 [12.3%; 95% CI, 11.7%-12.9%]; P < .001) (Table; Figure, A). However, there were substantial differences by subspecialty (Table; Figure, B). The percentage of UIM fellows was unchanged in geriatrics (63 of 301 [20.9%; 95% CI, 16.7%-25.9%] to 31 of 214 [14.5%; 95% CI, 10.4%-19.8%; P = .19), hematology/oncology (84 of 1164 [7.2%; 95% CI, 5.9%-8.8%] to 154 of 1674 [9.2%; 95% CI, 7.9%-10.7%]; P = .28), pulmonary/critical care medicine (114 of 1087 [10.5%; 95% CI, 8.8%-12.4%] to 178 of 1726 [10.3%; 95% CI, 9.0%-11.8%]; P = .31), and rheumatology (42 of 366 [11.5%; 95% CI, 8.6%-15.1%] to 57 of 477 [11.9%; 95% CI, 9.4%-15.2%]; P = .90) but increased in cardiology (206 of 2142 [9.6%; 95% CI, 8.4%-10.9%] to 316 of 2731 [11.6%; 95% CI, 10.4%-12.8%]; P < .001), endocrinology (56 of 486 [11.5%; 95% CI, 9.0%-14.7%] to 115 of 666 [17.3%; 95% CI, 14.6%-20.3%]; P < .001), gastroenterology (101 of 1097 [9.2%; 95% CI, 7.6%-11.1%] to 184 of 1525 [12.1%; 95% CI, 10.5%-13.8%]; P < .001), infectious diseases (98 of 679 [14.4%; 95% CI, 12.0%-17.3%] to 133 of 731 [18.2%; 95% CI, 15.6%-21.2%]; P < .001), and nephrology (110 of 822 [13.4%; 95% CI, 11.2%-15.9%] to 131 of 834 [15.7%; 95% CI, 13.4%-18.3%]; P < .001). The highest percentage of UIM fellows over time was in infectious diseases, and the lowest was in hematology/oncology.
The data on UIM residents and fellows from 2018 are shown in the Table and Figure, C. Compared with IM residencies, there were 4 subspecialty fellowships with higher percentages of UIM trainees (ie, infectious diseases, endocrinology, nephrology, and geriatrics) and 5 with lower percentages (ie, gastroenterology, rheumatology, cardiology, pulmonary/critical care medicine, and hematology/oncology). All specialties had considerably lower percentages of UIM trainees than in the US population (US population: black or African American, 1.4%; American Indian or Alaska Native, 1.3%; Native Hawaiian or other Pacific Islander, 0.2%; Hispanic or Latino, 18.3%).5
Between 2006 and 2018, the overall percentage of UIM subspecialty fellows increased but with substantial variation by specialty. The current state of diversity in subspecialty fellowships still requires attention. In 2018, no specialties reflected the diversity of the US population, and more than half had lower percentages of UIM trainees than IM residencies—a useful benchmark, given that residents are the direct pipeline for subspecialty fellows. With the exception of rheumatology, the subspecialties with the lowest percentages of UIM fellows were also the largest fellowships and the more procedural specialties. This raises questions about possible factors that may be affecting career choice for UIM residents; further research is needed to elucidate these. Moreover, there is overlap between the UIM and gender breakdown in IM subspecialties,2 with higher percentages of UIM and women in specialties such as infectious diseases, endocrinology, and geriatrics.
A limitation of our study is that Graduate Medical Education census data are imported from Association of American Medical Colleges databases with self-designated race/ethnicity when available, but otherwise, race/ethnicity is reported by program directors. Because fellows are the future subspecialty workforce, there is an urgent need to recruit and retain UIM trainees in all IM subspecialties, in particular in those with a disproportionately low and/or unchanged percentage of UIM trainees over time.
Accepted for Publication: December 6, 2019.
Published: February 7, 2020. doi:10.1001/jamanetworkopen.2019.20482
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Santhosh L et al. JAMA Network Open.
Corresponding Author: Lekshmi Santhosh, MD, MAEd, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143 (firstname.lastname@example.org).
Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Both authors.
Administrative, technical, or material support: Santhosh.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grant UL1 TR001872 from the National Center for Advancing Translational Sciences.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Meeting Presentation: This article was presented in part in a poster presentation at IDWeek 2018 of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, the HIV Medical Association, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists; October 3 to 7, 2018; San Francisco, California.
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