The COVID-19 pandemic has shed light on America’s health inequities in terms of the provision of care. It is also creating a conversation around their existence in medical education, and the need for structural interventions that address inequities and foster long-term change in physician training.
Recent AMA guidance on protecting underrepresented students and residents during COVID-19 offered a view of the challenges these learners face—both before and during the pandemic—and how the educational system can address them. It’s no accident that the document was published during a period in which the national dialogue around inequality was emerging.
“People seem to be really open to understanding the structural elements that drive inequality,” said Kim Lomis, MD, the AMA’s vice president for undergraduate medical education innovations. “This is a conversation. This is an opportunity since there is more light being shed on these situations. We all have work to do. The AMA itself is trying to overcome a history of exclusion. These recommendations are meant to get people talking and sharing resources about how we can do a better job and give voices to students who have been raising these concerns.”
Pre-existing educational conditions
Even prior to the pandemic, medical education was already losing ground with respect to racial and ethnic parity. A 2019 study found that in spite of medical school enrollment doubling over the past two decades, the percentage of entering under-represented students actually fell by 16%.
Efforts to address that reality, in part spearheaded by 37 member schools of AMA’s Accelerating Change in Medical Education Consortium, were underway prior to the pandemic. Still, the disruptive forces of COVID-19 are felt more acutely by students from disadvantaged backgrounds.
The AMA’s guidance offers several examples of situations in which that has been the case. Among them:
- The shift to virtual platforms of educational delivery has revealed inequities—including lacking internet and device access and proper workspaces—that may further limit the academic achievement of students from under-resourced urban and rural communities.
- Students are losing enrichment activities—such as research, shadowing, global health experiences and clinical electives—that carry increased importance to candidates who are from backgrounds underrepresented in medicine or who have perceived weaknesses in aspects of their portfolios.
- Geographic inconsistency in administration of standardized testing—notably administration of the
- Medical Colleges Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step examinations—means some students have to consider travel for testing, which will amplify existing disparity in access.
Students from underrepresented backgrounds are also coping with the larger societal effects of the pandemic, with people of color experiencing COVID-19 disproportionately and communities of color feeling a greater financial burden from the toll the virus has taken on the economy. “Thinking about the recent events highlighting social injustice, if you are in a group that has been marginalized from medicine, you are experiencing this cultural phenomenon in a different way than those who are in a more protected position. The distraction from coursework, the desire to be engaged in the social dialogue is perhaps stronger for those students,” Dr. Lomis said.
“We need to be aware of the fact that this is disrupting education for all of our students and pre-medical students, but it will have a worse impact for some students than others.”
Moves to address inequality
As a response to the rising inequality in medical training, the AMA offered several suggested interventions medical schools and residency programs could implement:
- Increase attention to structural determinants of academic success and provide a clear process by which students can report challenges and seek assistance.
- Engage students, residents and faculty from underrepresented backgrounds in the process of planning adjustments to curriculum, assessment and application processes to better consider the diverse circumstances of students.
- Amplify efforts to create inclusive learning and working environments across the continuum of pre-medical education, medical school, graduate medical education and practice.
- Heighten monitoring of learner well-being at all levels of medical education and minimize barriers to mental health care.
The guidance also called for significant adjustments to the medical school admissions and residency selection processes, both of which have been upended by the pandemic. Because of learning disruptions across the educational continuum, the guidance also makes suggestions to undergraduate institutions that could be teaching future physicians.
“The timing of this guidance was important to us,” Dr. Lomis said. “We are entering the beginning of a medical school admissions and residency selection cycle. As we started to learn what was happening to certain medical students, we began to realize that parallel things were happening to some students in college. So, the collegiate level is included because those students will be differently prepared and have different challenges as they try to enter the medical profession. We want medical school admissions teams to be really conscious of that as well.”
The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time.