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In this episode, we’re joined by Heidi Chumley, dean at the Ross University School of Medicine, to discuss the barriers facing aspiring physicians in their journey to residency. Heidi will delve into the challenges of the residency matching process, including the cost of applications and travel expenses, as well as bias based on USMLE scores and discrimination in residency programs. She will also discuss the steps her medical school is taking to increase diversity and support its students in their journey to become successful resident physicians. With a 96 percent first-time residency attainment rate, Heidi provides valuable insight into the challenges and solutions in this important aspect of the health care industry.
Heidi Chumley is dean, Ross University School of Medicine.
She shares her story and discusses her KevinMD article, “Proposing solutions to end bias in the medical residency selection process.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Heidi Chumley. She’s a family physician, and she’s the dean at the Ross University School of Medicine. Her most recent KevinMD article is “Proposing solutions to end bias in the medical residency selection process.” Heidi, welcome back to the show.
Heidi Chumley: Thank you, Kevin. It is great to be back.
Kevin Pho: So you’ve been on the show multiple times. For those who want to hear Heidi’s story, just click on the upper right-hand corner and search for Heidi’s name to find previous episodes where she shares her story. But today we’re going to jump straight into your most recent article, which is “Proposing solutions to end bias in the medical residency selection process.” Now tell us, how did this article come together?
Heidi Chumley: Yeah, absolutely. So as you mentioned, this is the third time, I think, I’ve been with you, and it is the third part in a series of articles. The series of articles began with some barriers around getting into medical school, then some challenges in being successful in medical school, and this one really gets to the continued challenges that people have as they look for and enter residency programs. So it’s part of a series and continues the same purpose, which is really just to shine a bit of a light on some of the things about our system that make navigating this whole process more difficult for some of us than others.
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Kevin Pho: All right, so tell us, what is the situation today? How are these medical students and residents facing bias today?
Heidi Chumley: One of the things that we know is that the number of residents who identify as underrepresented minorities is a smaller percentage than those who do so in medical school, and certainly a smaller percentage than in the general population. What we also know is that the residents who don’t make it through, who actually don’t make it through their residency, are overrepresented, if you will, by underrepresented minorities. So we’ve got groups of people who are not only less likely to be in residency but less likely to finish.
As I was working on this series of articles and got to this point, it’s sort of natural to compare. What is happening around the time people are being selected for residency has a lot of parallels to what is happening around the time people are being accepted for medical school, and I can give just a couple of examples that I think will make this come to life a little more.
Just as when people are being evaluated for medical school, where they went to college makes a difference. There are people who are thought of differently if they’ve attended community college than if they’ve attended a tier-one school. I think we all sort of realize people make very different decisions about where they may go to school, and some of that is based on the opportunities that they have, the amount of money that they can spend, what they know, etc. So fast-forward: Now you’ve got a group of people who have made those types of decisions. They end up in different types of medical schools, and certainly during the residency selection process, there’s a very different opinion of people who are entering the process based on the type of medical school that they went to, whether it was a U.S. allopathic or an international medical school. That can certainly continue to perpetuate some of the challenges that our students have.
But the second example I would give is that you may start off in medical school with a bit of a gap to close. I think we’ve talked about this before: A lot of times the level of preparation of people as they come into medical school can differ based on the opportunities they’ve had in life up to that point. If you come in with a bit of a gap to close, then as you get to the residency selection process, the same things that you were a little bit behind on, if your MCAT score wasn’t as high as some of your peers’, generally translate into a Step 1 score that is not as high as your peers’. We’re almost to pass/fail on Step 1, but generally the score has been really very important. And it may translate into a Step 2 CK score that is passing, that is meeting the bar, meeting the level that is required to become a physician, but it may look lower than some of your peers’. Those are, again, I think, good examples of how something can just perpetuate its way through the system and continue to cause some challenges.
Kevin Pho: Now, when you talk about the different residencies, are there any specific ones where you feel unconscious bias is a little bit more prevalent, primary care specialties versus surgical specialties, for instance?
Heidi Chumley: Oh, you’re going to get me in trouble. No, I think it’s actually fairly pervasive throughout the discipline of medicine, and as a physician myself, I can see where that comes from, right? I mean, we like to believe and hold on to, if you will, the idea that every bit of the success we’ve had in becoming physicians comes from our own hard work and gifts and skills. And while I don’t at all want to diminish anybody’s hard work and gifts and skills, not even my own, there is a realization, I think, that people have to come to at some point in time, just understanding if they’ve had a different level of opportunity than other people. In my own background, I had a different level of opportunity. I came from a place that had a lot of opportunity, and I know that, and I realize that.
I don’t know that that realization is spread differently across different specialties. My own background is in primary care, so I like to think we see such a broad swath of the population, but I don’t know that it’s really contained to any specialty or not. The one thing I would say is that there are clearly some specialties that are more competitive than others, and the more competitive a specialty is, I think the harder it is to really figure out how you’re going to make selections about who gets to enter that profession.
Kevin Pho: Now, what are some of the things that medical students can do to even the playing field, so to speak, when it comes to underrepresented minorities applying to residency?
Heidi Chumley: Yeah, so great question. I would give a couple of pieces of advice. One is that the network is really, really important. You need to have mentors. You need to have people who understand the specialty that you’re interested in. Make those connections while you’re in medical school. Get your medical school to help you if you can’t find those connections on your own. But the network remains very important in medicine, and in understanding and coming across as the type of person that somebody’s going to select for their residency program.
The second piece of advice I would give people, particularly as we see more and more of the specialties begin to use signaling, and I don’t know if that has come up in some of your shows or not.
Kevin Pho: Tell us about that.
Heidi Chumley: OK, certainly. So a few years ago, in an effort to perhaps make it a little bit easier for residency program directors to figure out who to invite for interviews, a new process called signaling was introduced. It’s a choice of each discipline, and it’s a choice of the student to engage in this process, but I think about 19 specialties this year, as we headed into the Match, had a signaling program. What that allows a student to do is say to a specific program, “Hey, I’m particularly interested in your program.”
As you can imagine, every specialty went about this differently, right? If you know the differences in the specialties, some specialties have very few, like three signals. Think about it: You’re going to apply to a bunch of places, and you get three. Some have a lot more, 15 or 20, in that range. And there’s becoming a bit of a strategy around this. So the second thing I would tell people is to really understand and read everything you can about the signaling process if you’re entering a program that is using it. It’s new, so the more you know about it and how to use it, how to strategize and help it work for you, I think the better off you’re going to be.
And the third thing I always tell people is that you’re going to have to stand out. You’re going to have to stand out for some reason, and one of the best ways to stand out with any particular program is to show your compatibility with that program, whether it is that you’re from the same state or you understand the patient population they work with and that’s the patient population you want to work with. Any way you can, on an individual level with programs, attach yourself to something that is very specific to them, because it goes a really long way. It means you’ve got to do a lot of homework, particularly if you’re applying to a lot of programs, but it is something that’s very important.
Kevin Pho: Now, you’re a medical school dean, and you’ve written a series when it comes to some of the disadvantages underrepresented medical students have and some of the disparities. Why is that so important to you? Why are you so passionate about this topic?
Heidi Chumley: Yeah, you know, I spent the first part of my career in senior leadership at a U.S. medical school, and we did all the things, I think, that continue to be talked about as ways to diversify the physician workforce, and we really thought of ourselves as doing holistic admissions, etc. But then, when I made the move out to the Caribbean 10 years ago and began to talk with the students, it’s just story after story of these very remarkable people who had lives so different from mine and managed to find their way to medicine against so many different odds. And then just to watch them grow, cross the stage, graduate, and get into residency programs, that is what has really made this a passion for me.
And then, as with anything, you can get better at it, right? Because not everyone who comes is successful. But you can learn how to really work with people to find out all the different things that can be impeding their success and partner with them. And the more people with the types of stories that I get to hear every day who get into medicine, I think it makes us all better off.
Kevin Pho: Tell us one of these stories. I know I’m putting you on the spot here, but give us an example of one of those stories that particularly struck you about some of your students where you work.
Heidi Chumley: Yes, I will. I’m not going to give her name, of course, but she might recognize herself if she listens to your show. We recently had a graduate who went to a program up in the north. She got a residency position, her first choice, up in the north, and this was her first choice because she had worked there. She had actually worked in that hospital, and the reason she worked in that hospital for six years was because she was a single mom. She did well in college, but she had a baby at age 17. She made it through college with great scores, but she actually did not think that she was going to be able to do medical school. She certainly heard from a lot of people who said, “That’s not for you. You’re a young mom,” etc.
She worked for six years, and then she decided to go back to Memphis. She found Ross, went there with her young child, graduated, and then went back into a residency program at the very hospital where many people had discouraged her from pursuing this, and the one that was attached to the medical school that had rejected her. So it’s those kinds of stories that really make it worth it.
Kevin Pho: Now, from a more macro perspective, what would you like to see fixed when it comes to the residency standpoint in order to decrease some of these biases? If you’re in charge, what would you like to see fixed? How would you do that?
Heidi Chumley: Yeah, well, tactically, I would turn off the filter that lets residency program directors filter by international school or U.S. But I absolutely understand that so many applications come in and that they need to have some filters. So other than that very tactical move, which I wouldn’t actually get to do, it would be helping people really just get over this idea that the only people who are in international medical schools are there because of something that they did not do as well as their U.S. counterparts.
If I could just change that one mindset and have people take a look at students, or I guess they’re doctors at this point, at the doctors who really had to take a different pathway, who cared so much about wanting to be a physician that they were willing to take a different pathway. Just take a look. You don’t have to choose them; choose who you think is best. But give them a look. That would be the one thing that I would change.
Kevin Pho: We’re talking to Heidi Chumley. She’s a family physician, and she’s a dean at the Ross University School of Medicine. Her KevinMD article is titled “Proposing solutions to end bias in the medical residency selection process.” Heidi, tell us some of your take-home messages that you want to leave with the KevinMD audience.
Heidi Chumley: Well, I think I would come back to some of the things I’ve said to your audience before, which is that if you are a practicing clinician, you are often in a place of opportunity to make a big difference in people’s lives. Whether they are people who come to shadow in your office who are thinking about medicine, or whether they are learners who are rotating with you, you really do have an opportunity to learn their story and to understand where they may be coming from.
And for the group of people who have had a very different set of opportunities than many of us may have had, maybe similar to whoever I’m talking to, but for that group of students, give them a level of encouragement. Show them that they can enter the health professions, enter medicine, if that’s the one that they’re interested in, and then help them understand the pathways to do that. So that would be my only ask, just that one thing.
Kevin Pho: Heidi, thank you so much for sharing your time and insight again. Thanks for coming back on the show.
Heidi Chumley: Yeah, thank you, Kevin.
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