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The evaluation of in-person versus virtual interviews from underrepresented minorities in medicine

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The evaluation of in-person versus virtual interviews from underrepresented minorities in medicine

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The Evaluation of In-Person Versus Virtual Interviews from Underrepresented Minorities
in Medicine
by
Sandra Gonzales, M.S.

Rossier School of Education
University of Southern California
A dissertation submitted to the Faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2023

© Copyright by Sandra Gonzales 2023
All Rights Reserved

The Committee for Sandra Gonzales certifies the approval of this Dissertation

Jennifer L. Philips
Victor Cisneros
Helena Seli, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
Each year, thousands of medical residency and fellowship applicants apply to medical residency
programs in the United States. The residency interview is a critical component of the application
progress. The problem being addressed by this study is that it is unknown whether in-person or
virtual interviews are more beneficial for minority and underrepresented physicians. The purpose
of this study was to examine the experiences of minority physicians who participated in different
interview modalities to determine whether there are patterned differences that may provide a
disadvantage for residency and fellowship applicants from minority or under privileged
backgrounds. To this end, a mixed methodological study was employed whereby minority
physicians applying to a residency and fellowship programs at a teaching hospital in the western
United States recounted their experiences with racial microaggressions and implicit bias in their
residency and fellowship interviews. Semi-structured interviews with participants indicated that
they experienced similar types and frequencies of racial microaggressions and implicit bias in
their in-person and virtual interviews. Quantitative surveys of participants indicated that
participants experienced the invisibility and assumption of criminality microaggressions more
frequency than the other types of microaggressions surveyed. Recommendations for improving
the experiences of minority resident applicants are provided. This study has implications for
equity, as the findings and results can be used to understand and enhance the equitable treatment
of minority physicians in their medical residency and fellowship interviews, which may have
implications for increasing diversity in the medical healthcare workforce.

v
Dedication (Optional)
To my mom, whose unwavering faith, enduring love, and countless sacrifices were my
encouragement of light in the darkest hours, thank you for molding me into who I am today.
Even when I doubted myself, your unwavering belief in me served as my compass, leading me to
complete this journey.

In loving memory of my father, who was the very purpose and inspiration behind my pursuit of
knowledge and attainment of all my degrees. His ever-present spirit guided me through the trials
and tribulations, reminding me of the strength he knew I possessed. In his memory, I endeavored
to go beyond the realm of the possible, and his words of wisdom still resonate within me, fueling
my academic and personal growth. Dad, I believe you are watching over me, and I hope I have
made you proud.

To my Chica (twin sister), family, and friends, your constant encouragement and love have been
a source of comfort and motivation in times of struggle. You've been there to celebrate every
small victory and provided support in every setback.

Each of you has contributed to this monumental milestone in my life, and I am forever grateful
for that. This dissertation is not just my accomplishment; it is ours. Fight on!

vi
Acknowledgements
I would like to first express my most profound appreciation to the ever-resilient Cohort
19. To Noel, Michael, Lesley, and my colleagues, who have been with me on this challenging
journey, you have been more than just peers; you have been an ensemble of inspiration,
encouragement, and camaraderie. Thank you for your unwavering support, which has played a
vital role in my academic growth. We got this!
To my dissertation committee, your guidance, mentorship, and expertise have been the
pillars of this study. My chair, Dr. Seli, your constructive criticism and suggestions have shaped
my research and writing into something I am proud to present today. A special acknowledgment
goes to my editor, CM, who worked tirelessly to ensure my work was well-presented and
communicated effectively.
I am also deeply grateful to my colleagues at Eisenhower Health. Thank you, ladies, for
helping me through the doctoral application process. Despite our demanding professional lives,
you offered constant encouragement, understanding, and support during trying times. Gigi, my
right hand and biggest cheerleader, thank you for steadily standing in my corner no matter what.
Lastly, I want to express my heartfelt gratitude to Rick. You broadened my perception of
success, which led me on this path toward earning a doctoral degree. I truly appreciate your
endless love, patience, and support during this journey.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication (Optional) ..................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. ix
List of Figures .................................................................................................................... xi
List of Abbreviations (Optional) ................................................................................................... xii
Chapter One: Introduction to the Problem of Practice .................................................................... 1
Background of the Problem ................................................................................................ 2
Organization Context and Mission ..................................................................................... 4
Purpose of the Study and Research Questions .................................................................... 5
Importance of the Study ...................................................................................................... 6
Overview of Theoretical Framework and Methodology .................................................... 7
Definitions........................................................................................................................... 7
Organization of the Dissertation ....................................................................................... 10
Chapter Two: Review of the Literature ........................................................................................ 11
Medical Residency: History, Involved Professionals, and Significance .......................... 12
Background of Underrepresented Minorities in Medicine ............................................... 18
Role of Academic Medicine in Developing URiM Physicians ........................................ 28
In-Person Medical Residency Interviews Versus Virtual Interviews ............................... 34
Strategies for Mitigating Microaggressions and Bias in Interviews ................................. 45
Critical Race Theory ......................................................................................................... 46
Conclusion ........................................................................................................................ 51
Chapter Three: Methodology ........................................................................................................ 53
Research Questions ........................................................................................................... 53

viii
Overview of Methodology ................................................................................................ 54
The Researcher .................................................................................................................. 57
Data Sources ..................................................................................................................... 59
Ethics................................................................................................................................. 73
Chapter Four: Results or Findings ................................................................................................ 77
Participants ........................................................................................................................ 78
Overall Findings ............................................................................................................................ 82
RQ1: How, If at All, Do URiM Residency and Fellowship Applicants Experience
Implicit Bias and Microaggressions In the Interview Process? .................................................... 83
RQ2: Differences in URiM Residency and Fellowship Applicants’ Experiences Based on
Interview Modality ...................................................................................................................... 113
RQ3: Difference in Residency or Fellowship Offers Based on Interview Modality .................. 119
Summary of Results and Findings .................................................................................. 122
Chapter Five: Discussion and Recommendations....................................................................... 124
Discussion of Findings .................................................................................................... 124
Recommendations for Practice ....................................................................................... 127
Recommendations for Future Research .......................................................................... 134
Implications for Equity ................................................................................................... 134
Conclusion ...................................................................................................................... 135
References ................................................................................................................................... 138
Appendix A: RMAS Survey ....................................................................................................... 169
Appendix B: Interview Protocol ................................................................................................. 172
Appendix C: Recruitment Flyer .................................................................................................. 174
Appendix D: Information Sheet for Exempt Studies .................................................................. 175

ix
List of Tables
Table 1: Summary of Pros and Cons of Virtual and In-Person Interviews 44
Table 2: Data Sources 57
Table 3: URiM Applicants to Residency and Fellowship Programs at MMC 79
Table 4: Interview Participants’ Demographic Characteristics 82
Table 5: Participants’ Experiences of Microaggressions in their Residency Interviews 84
Table 6: RMAS Survey Data for Foreigner in own Land Microaggression 86
Table 7: Summary Statistics for Foreigner in Own Land Microaggression 87
Table 8: ANOV A Table for Foreigner in Own Land Microaggression 87
Table 9: RMAS Survey Data for Exoticization or Sexualization Microaggression 92
Table 10: Summary Statistics for Exoticization or Sexualization Microaggression 92
Table 11: ANOV A Table for Exoticization or Sexualization Microaggression 93
Table 12: RMAS Survey Data for Assumption of Criminality Microaggression 98
Table 13: Summary Statistics for Assumption of Criminality Microaggression 99
Table 14: ANOV A Table for Assumption of Criminality Microaggression 100
Table 15: Post-Hoc Tukey Test for Assumption of Criminality Microagression 101
Table 16: RMAS Survey Data for Low Achieving or Undesirable Culture Microaggression 103
Table 17: Summary Statistics for Low Achieving or Undesirable Culture Microaggression 104
Table 18: ANOV A Table for Low Achieving or Undesirable Culture Microaggression 105
Table 19: RMAS Survey Data for Environmental Microaggressions 107
Table 20: Summary Statistics for Environmental Microaggressions 108
Table 21: ANOV A Table for Environmental Microaggressions 109
Table 22: RMAS Survey Data for Invisibility Microaggressions 110

x
Table 23: Summary Statistics for Invisibility Microaggressions 111
Table 24: ANOV A Table for Invisibility Microaggressions 111
Table 25: Post-Hoc Tukey Test for Invisibility Microaggressions 112
Table 26: URiM Physicians Interviewed and Matched in MMC Programs 2019-2023 121
Table 27: Number of Matched URiM Physicians Interviewing Virtually or In-Person 121

xi
List of Figures
Figure 1: Survey Participants’ Gender Identities 79
Figure 2: Survey Participants’ Ethnicities 80

xii
List of Abbreviations (Optional)
ACGME Accreditation Council for Graduate Medical Education
AAMC Association of American Medical Colleges
ERAS Electronic Residency Application Service
GME Graduate Medical Education
NRMP National Resident Matching Program
URiM Underrepresented Minorities in Medicine
USMLE United States Medical Licensing Examination

1

Chapter One: Introduction to the Problem of Practice
With the U.S. population becoming more diverse, there is a high demand of physicians
from racial and ethnic groups that are described as underrepresented in medicine (URiM)
(Bonifacino et al., 2021). The URiM groups include women, people with disabilities, Blacks,
Latinx, Asians, Native Americans, and Alaskans. Although these groups account for one-third of
the population, they comprise less than 15% of the medical residency workforce (Crites et al.,
2022). Moreover, when examining the proportion of all physicians in 2019, Black and Latinx
physicians made up only 5% and 5.8% of the U.S. physicians, respectively (Usoro et al., 2021).
In order to improve the diversity of practicing physicians, it is imperative to identify ways to
recruit and retain physicians from racially diverse groups.
Medical residency or postgraduate training is a stage of graduate medical education that
occurs after obtaining a doctorate degree in medicine (ACGME, 2022). A medical residency
program takes place in a hospital or clinic providing comprehensive training within a specific
medical specialty for physicians who have graduated from medical school (ACGME, 2022).
Traditionally, in-person interviews have been a key part of residency selection processes. In
2020, the COVID-19 pandemic caused a paradigm shift in the residency application process,
necessitating a shift from in-person to virtual interviews. The Association of American Medical
Colleges (AAMC) allowed residency training programs to conduct interviews via different
modalities (Marbin et al., 2021a). As programs strive to recruit and retain a diverse workforce,
researchers question whether virtual interview formats will be subject to bias that can further
disadvantage residency applicants from underrepresented racial backgrounds (Nwora et al.,
2021). Hence, it is essential to explore the URiM applicants’ experiences of in-person versus
virtual interviews to identify and improve strategies in increasing diversity with graduate medical
2

education. Specifically, this study examined the prevalence and types of racial microaggressions
and implicit bias experienced by URiM physicians during their medical residency and fellowship
interviews. A microaggression is an unconscious action that is deemed racially discriminatory
against a marginalized group; implicit bias is unconscious discrimination in favor or against one
individual or groups (Turner et al., 2021). Racial microaggressions can dramatically influence a
physician’s enthusiasm and commitment to their program and practice (M. S. Williams et al.,
2023). Thus, addressing microaggression and implicit bias present in virtual and in-person
residency and fellowship interviews is a necessary step in recruiting, retaining, and training
URiM physicians.
Background of the Problem
According to the Associated Medical Schools of New York [AMSNY] (2020), the
AAMC estimates that by 2032, the United States will see a physician shortage of nearly 122,000
doctors. The shortages will be felt most acutely in underserved areas, and increasing the number
of physicians from underrepresented backgrounds will be a key to addressing the looming crisis
(Aibana et al., 2019). Previous studies demonstrate that physicians from racial or ethnic
backgrounds underrepresented in medicine are more likely to practice primary care and practice
in underserved areas while treating many minority patients, irrespective of income (AMSNY,
2020). Therefore, embracing diversity can result in several positive benefits, such as increased
care in underrepresented communities, improved familiarity with cultural differences in patients,
and continued research into health care disparities (Khan et al., 2019).
Although diversity in the physician workforce has multiple advantages, residency
programs have struggled to attract residents with URiM backgrounds. There are many factors
contributing to a lack of diversity, particularly in the residency application process, also called
3

the “Match.” During the last year of medical school, students register for the National Resident
Matching Program (NRMP) which ensures that the residents are a proper fit for the residency
program in which they are placed (Dooley et al., 2021). According to Gonzaga et al. (2020),
most residency programs receive many residency applications that can be most easily sorted in
the Electronic Residency Application Service (ERAS) according to United States Medical
Licensing Examination (USMLE) test scores. This screening technique results in bias against
URiM students, who have been found to score worse on standardized tests than their White peers
(Gonzaga et al., 2020). Additionally, the residency program director can review URiM applicants
based on their self-identified race or ethnicity in ERAS using the same universal criteria as non-
URiM applicants, which may reflect stereotypical preconceptions (Gonzaga et al., 2020). Due to
these systematic biases, AAMC recommends that residency programs have multiple faculty
members read applications, including a representative for the diversity, inclusion, and equity
committee for each residency program (Marbin et al., 2021a).
Following the screening of applicants, residency programs generally facilitate in-person
interviews; however, due to COVID-19 pandemic, travel restrictions required all residency
programs to suspend in-person interviews and adopt a virtual interview process. According to
Fuchs and Youmans (2020), virtual interviews offer several advantages over traditional in-person
interviews, including greater convenience, reduced costs for applicants and programs, increased
scheduling flexibility and mitigation of geographic limitations. Despite these advantages, there
are disadvantages to virtual interviews, including hindering the opportunity for URiMs to
network with faculty and residents, showcase their abilities, and tour the institution (Ngonadi &
Barbosa, 2021).
4

Residency training programs serve as the gatekeepers for the physician workforce.
Efforts to improve diversity at the residency level will impact the diversity of practicing
physicians (Crites et al., 2022). Organizations at both the state and national levels recognize
diversity and stress its importance; therefore, to ensure an equitable recruitment and selection
process, the AAMC suggests using holistic review, defined as “a flexible, individualized way of
assessing an applicant's capabilities by which balanced consideration is given to experiences,
attributes, and academic metrics” (Marbin et al., 2021b, p. 195). However, the implementation of
holistic review may differ among residency programs, as the process requires substantial
institution-wide commitment. Virtual interviews may result in less interaction with faculty
compared to in-person interviews, resulting in students earning a lower ranking than non-URiM
applicants (Makkad & Deshpande, 2022). Thus, it is essential for residency programs to create a
straightforward process for interviewing to combat any potential for bias and limit unintended
effects on URiM applicants.
Organization Context and Mission
During the last year of medical school, students submit their residency application, which
includes a compilation of materials demonstrating their qualifications for a specific specialty.
The medical students then select and apply to a residency program in a medicine specialty, based
on various factors, including personal and clinical experience. Residency is a period of advanced
training in a medical specialty that typically follows graduation from medical school and
licensing to practice medicine. Residents are trained in patient care alongside other health
practitioners and with supervision from attending physicians. They are exposed to various
services, care settings, patients, and cases, as well as cutting-edge research care, preparing them
5

to treat the full range of patients regardless of where they decide to practice after completion of
their training program.
The research setting was Monterey Medical Center (MMC, pseudonym), a community-
based academic center located in the western United States that trains more than 125 residents in
multiple ACGME-accredited programs. MMC’s mission is to recruit and train a diverse group of
physicians by providing an academic and clinical environment that will set future leaders and
innovators of medicine up for success in improving the health of patients and underserved
communities. In 2019, MMC’s annual survey revealed that 50% of their patients come from
underserved populations and 40% of patient encounters involve patients identifying as Black or
Latinx. Despite the diverse patient population, the racial and ethnic diversity of the residents
training at MMC is currently 5% Latinx and 3% Black. Given the limited candidate pool and the
selection process that contributes to discrepancies, recruiting URiM residents can be challenging.
In 2019, several common program requirements were enacted by the Accreditation Council for
Graduate Medical Education (ACGME) to address issues of diversity, equity, and inclusion
(ACGME, 2021). MMC acknowledges the necessity for diversity and equity initiatives and is
committed to strategizing and taking specific steps, with diversity recruitment at the forefront.
Purpose of the Study and Research Questions
The purpose of this study was to examine the experiences of URiMs who participated in
different interview modalities to determine whether there are patterned differences that may
provide a disadvantage for residency and fellowship applicants from URiM backgrounds. This
dissertation aimed to ultimately distinguish how in-person and virtual interviews may impact the
recruitment and selection process of URiM physicians and make recommendations to improve
6

strategies in increasing diversity within graduate medical education. Three research questions
guided this study:
1. How, if at all, do URiM residency and fellowship applicants experience implicit bias and
microaggressions in the interview process?
2. Are there any differences in URiM residency and fellowship applicants’ experiences of
bias and microaggressions based on whether they interviewed in-person or virtually?
3. Is there a difference in the percent of URiM physicians receiving a residency or
fellowship offer based on whether they interviewed in-person or virtually?
Importance of the Study
In the past decade, the number of residency applications has grown steadily, but there has
not been a significant increase in diversity among physicians (Aibana et al., 2019). In 2022, with
the increase in cases of the Omicron variant in combination with the ongoing COVID outbreak,
residency programs restructured their interview processes to include in-person and virtual
interviews, which have potential disadvantages to URiM candidates. While in-person interviews
allow URiM applicants to build relationships with faculty and residents over the course of the
interview period, virtual interviews provide less interaction with faculty and may result in them
earning a lower ranking than non-URiM applicants (Makkad & Deshpande, 2022).
Despite the uncertainty regarding the future of the residency interview process, virtual
interviewing is a common and growing practice that will continue to play a significant role in the
medical interview process. As residency programs gain more experience and collect more data
about their in-person and virtual interview experiences, it is essential to examine URiM
physicians’ experiences with in-person and virtual interviews to determine whether there are
patterned differences that may disadvantage URiM applicants. By conducting this research,
7

MMC will be able to evaluate the experience and outcomes of both interview approaches to
ensure equity.
Overview of Theoretical Framework and Methodology
Critical race theory (CRT) served as a theoretical lens to identify and address how
racism, gender, and microaggressions affect the interview experiences of URiM physicians. Over
several decades, CRT scholars in education have theorized, examined, and challenged the ways
in which race and racism explicitly and implicitly impact the educational structures, processes,
and discourses that effect People of Color (Solorzano & Yosso, 2001). This theory is critical and
different because (a) it challenges traditional paradigms, texts, and discourse about race, class,
and gender; (b) it examines the effects of racism from the perspective and experiences of women
and men of color; and (c) it proposes ways to transform oppressive social conditions in which
women and men of color find themselves (Solorzano, 1998).
For this study, a mixed method research design was used, integrating both qualitative and
quantitative research methods. An explanatory sequential design was used to explore URiM
physicians’ experiences of bias or microaggressions during the interview processes. Quantitative
data was collected to determine whether there were differences between the URiM physicians’
experiences regarding bias and microaggressions experienced during the interview process.
Qualitative data was gathered to understand the participants’ experiences in virtual and in-person
interviews in more depth.
Definitions
● Accreditation Council for Graduate Medical Education (ACGME) is an independent,
501(c)(3), not-for-profit organization that sets and monitors voluntary professional
8

educational standards essential in preparing physicians to deliver safe, high-quality
medical care to all Americans (ACGME, 2022).
● Association of American Medical Colleges (AAMC) is a not-for-profit association
representing all 136 accredited U.S. and 17 accredited Canadian medical schools; nearly
400 major teaching hospitals and health systems, including 62 Department of Veterans
Affairs medical centers; and 93 academic and scientific societies (AAMC, 2022).
● Electronic Residency Application Service (ERAS) streamlines the residency application
process for applicants, their Designated Dean's Offices, Letter of Recommendation (LoR)
authors and program directors. By providing applicants the ability to build and deliver
their application and supporting materials individually or as a package to programs,
ERAS provides a centralized, but flexible solution to the residency application and
documents distribution process (AAMC, 2022).
● Graduate Medical Education (GME) refers to the period of education in a particular
specialty (residency) or subspecialty (fellowship) following medical school (ACGME,
2022).
● Health Disparities is defined as a particular type of health difference that is closely linked
with economic, social, or environmental disadvantage. Health disparities adversely affect
groups of people who have systematically experienced greater social or economic
obstacles to health based on their racial or ethnic group, religion, socioeconomic -status,
gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation
or gender identity; geographic location; or other characteristics historically linked to
discrimination or exclusion (U.S. Department of Health and Human Services, 2022).
9

● Latinx is a person of Latin American origin or descent (used as a gender-neutral or non-
binary alternative to Latino or Latina) (Merriam-Webster, n.d.).
● National Resident Matching Program (NRMP), or The Match, is a private, non-profit
organization established in 1952 at the request of medical students to provide an orderly
and fair mechanism for matching the preferences of applicants for U.S. residency
positions with the preferences of residency program directors (NRMP, n.d.).
● Residency is a period of advanced training in a medical specialty that normally follows
graduation from medical school and licensing to practice medicine (Merriam-Webster,
n.d.).
● Residency Program Director is responsible for developing, overseeing, and improving
residency or fellowship programs, implementing changes based on the current
accreditation requirements, and preparing for accreditation site visits and review by the
ACGME Review Committees (ACGME, 2022).
● Underrepresented Minorities in Medicine is defined by AAMC as those racial and ethnic
populations that are underrepresented in the medical profession, relative to their numbers
in the general population. Hispanic/Latinx, Blacks/African Americans, and Native
Americans/American Indians, are the groups that remain persistently underrepresented in
medicine, compared to the U.S. population (AMSNY, 2020).
● United States Medical Licensing Examination (USMLE) is a three-step examination for
medical licensure in the U.S. The USMLE assesses a physician's ability to apply
knowledge, concepts, and principles, and to demonstrate fundamental patient-centered
skills that are important in health and disease and that constitute the basis of safe and
effective patient care (ACGME, 2022).
10

Organization of the Dissertation
An organization of this research is based on five chapters. In this chapter, the reader is
provided with key concepts and terminology commonly used in discussions related to the URiM
residency applicant perspectives of the recruitment interview process and its impact on
workplace diversity in graduate medical education. Moreover, the mission and goals of the
organization were discussed, particularly its commitment to strategizing and taking specific steps
with diversity recruitment at the forefront. Chapter Two provides a review of current literature
surrounding the root causes of underrepresentation of minorities in medicine and examines
relevant policies and potential interventions. Chapter Three details the methodology regarding
choice of participants, data collection and analysis. Chapter Four summarizes the results of the
quantitative data and qualitative findings of the study, while Chapter Five provides solutions
based on data analysis and literature reviews to address implementation needs and make
recommendations that will continue to be assessed over time.

11

Chapter Two: Review of the Literature
Improving diversity in the healthcare workforce can positively influence the health
outcomes of diverse patient populations. Thus, a greater diversity of graduate medical education
students has the potential to impact the physician workforce positively. The present study aimed
to examine the experiences of URiM physicians who participated in different interview
modalities to determine whether there are patterned differences that may provide a disadvantage
for residency and fellowship URiM applicants. The present study addresses important questions
regarding the virtual residency interview process, including whether URiM applicants
experienced differences in implicit bias or racial microaggressions between their virtual and in-
person interviews. If present, such differences could impact diversity in medicine, as upcoming
resident physicians make important decisions that could impact the trajectories of their careers.
The literature review is divided into three sections. The first section includes a discussion
of the history of medical residency and the various organizations involved in medical residency
programs, as well as the importance and significance of medical residency. One goal of the first
section is to provide insight regarding the importance of residency, factors contributing to a
potential lack of diversity in residency programs, and the professional identities of the
physicians, as well as how programs attempt to mitigate the gap of underrepresented minority
medical students and residents. Second, the literature review will include a discussion of
healthcare disparities among marginalized groups and the implicit bias and microaggressions
present in medicine. The final section will review in-person versus virtual experiences for
applicants and discuss how CRT served as a theoretical lens to identify and address how racism,
gender, and microaggressions affect the interview experiences of URiM physicians.
12

Medical Residency: History, Involved Professionals, and Significance
Medical residency training is a period of advanced medical training and education that
begins after a physician graduates from medical school and passes licensing examinations. To
practice medicine in the United States, physicians must complete residency training, consisting
of supervised practice of a specialty in a teaching hospital (Hoekzema et al., 2014). During
residency training, physicians learn the critical competencies required for the practice of
medicine, including clinical reasoning, communication and cinical skills, as well as specialty-
based technical skills (Oussalah et al., 2015). The goal of residency programs is to provide
physicians with the tools needed to provide quality and optimal patient care. Additionally,
residency programs are important for providing quality care to underserved communities in the
United States. The first section of the literature review discusses a brief history of medical
residency, and the various organizations involved in medical residencies and outlines the
importance and significance of the medical residency for physicians.
A History of Medical Residency
Residency programs have been critical and integral to the expansion and progression of
medicine (Carek et al., 2017). Eaton et al. (2020) mentioned that in the eighteenth and nineteenth
centuries, health care in the United States was unlicensed and unstructured; this situation was
remedied in the twenty-first century when medical training became more regulated. William
Stewart Halsted developed the first residency training program at Johns Hopkins Hospital,
which, in turn, became the model and standard for all other surgical and medical residency
training programs in the United States (J. R. Wright & Schachar, 2020). Halsted designed
residency programs in a formal and structured way, replacing the apprenticeship training model
(J. R. Wright & Schachar, 2020). One of the fundamental aspects of this residency model was a
13

tiered performance level so that residents may become more knowledgeable and experienced
while gaining more responsibility and independence as they progress through the program (J. R.
Wright & Schachar, 2020).
The Accreditation Council for Graduate Medical Education (ACGME) has continually
optimized residency training to provide the best patient care possible. ACGME is committed to
the ongoing monitoring of residents and fellows enabling safe, effective health care. ACGME
requires all residency programs to complete an annual program evaluation that examines the
curriculum, individual resident and graduate performances, faculty performance, and overall
quality of programs (Hoekzema et al., 2014). In addition to the ACGME, there are a variety of
institutions that play a role in enhancing and ensuring quality medical care, each of which will be
discussed in turn.
Organizations Involved in Medical Residencies
There are several organizations that are involved in the medical residency progress. Some
of these include ACGME, AAMC, ERAS and NRMP. These organizations help to transition the
applicant into a residency training program that will foster progressive responsibilities and
lifelong learning.
Role of Association of ACGME
The ACGME was established in 1981 as a not-for-profit organization that sets standards
and monitors professional educational standards critical for preparing physicians to deliver safe,
high-quality medical care (Maniar et al., 2019; Nicholson et al., 2014). The main goals of the
ACGME are to:
1. Help physicians with competency-based professional development.
2. Abide by evidence-based, data-based, clinical learning environments.
14

3. Provide safe, cost-effective, diverse, and inclusive care.
4. Provide a service-to-education balance (Maniar et al., 2019).
Importantly, the ACGME oversees residency programs by establishing and maintaining
accreditation standards and the quality of residency and fellowship programs, while promoting
residency education that addresses the quality and safety of patient care and aids in the learning
and professionalism of physicians (ACGME, 2022). ACGME also has a “Diversity, Equity, and
Inclusion for Composition of the ACGME Board and Committees” within its handbook
(ACGME, 2022, p. 12). The policy states:
The ACGME is committed to diversity, equity, inclusion, justice, and advocacy in all its
activities. In soliciting and selecting from among professionally qualified nominees or
applicants for ACGME committees, task forces, groups, appeals panels, and the Board of
Directors, consideration shall be given to diversity, including without limitation,
geography, specialty, gender identity, race, ethnicity, and sexual and gender minorities
(ACGME, 2022, p. 12).
In this way, the ACGME ensures that all practicing physicians have completed rigorous training
that enables the safe, efficient, and diverse practice of medicine.
Role of Association of American Medical Colleges
The AAMC is a popular nonprofit organization that represents medical schools, hospitals,
and academic societies. As part of its collaboration with its members and multisector community
partners, the AAMC promotes health equity, addresses public health crises, and ensures all
people have access to health care that is culturally responsive, diverse, and inclusive (AAMC,
2022). In addition, AAMC provides services that include data from medical, education, and
health studies (Kassebaum, 1992). The AAMC serves as the voice of medical schools and
15

teaching hospitals and encourages medical innovation and training for the next generation of
doctors.
The AAMC administers the Electronic Residency Application Service (ERAS)
application, which is necessary for entry into a medical residency, and also co-sponsors the
Liaison Committee on Medical Education (LCME) (AAMC, 2022). AAMC’s role in medical
residency is to streamline the residency application process for resident applicants and process
letters of recommendation, supplemental applications, and other components.
Role of Electronic Residency Application Service
The ERAS is a service provided by the AAMC (NRMP, n.d.). The ERAS portal is the
centralized online application service that delivers the residency application and supporting
documents to residency programs (A. Geary et al., 2021). The main role of ERAS is to allow
medical residency students to apply electronically to accredited U.S. graduate medical programs
(A. Geary et al., 2021; Wall et al., 2019). At the end of the interview period, residency applicants
create a rank-order list of programs with their top training choices, and these lists are then
submitted to the NRMP (Pourmand et al., 2018).
A. Geary et al. (2021) analyzed underrepresentation in medicine and the systematic
efforts to retain a diverse workforce. They examined ERAS data from eight residency programs
for two recruitment cycles, identifying self-identified race or ethnicity. The results showed that
medical students who identified as Black, Latinx, or Asian had fewer odds of being invited to an
interview compared to White students (A. Geary et al., 2021). Moreover, the findings
demonstrated that sharing ERAS data patterns with residency program directors is essential to
improving diversity. Such structured analysis of institutional ERAS data can help educators and
16

policymakers provide insight into the resident selection process and help with overall diversity in
medicine (A. Geary et al., 2021).
National Residency Matching Program, or The Match
Residency interviews are an important portion of the application process to U.S. graduate
medical education training programs. The National Resident Matching Program (NRMP or
“match”) was established in 1952 to improve residency enrollment (National Resident Matching
Program [NRMP], n.d.). The NRMP is a private, non-profit organization that is used for
matching applicants for U.S. residency positions (NRMP, n.d.). The Main Residency Match
contains more than 47,000 registrants and 39,000 positions (NRMP, n.d.). Moreover, this
organization is governed by a Board of Directors and national medical representatives. It is
noteworthy to mention that the NRMP uses a mathematical algorithm to assist applicants in
residency positions (Wall et al., 2019). The licensed “matching” algorithm allows applicants to
rank their preferred residency positions and matches these preferences with the program rank-
order list (Kirsch & Drolet, 2018; Wall et al., 2019). The rank order lists (ROLs) are the final
preferences of applicants and program directors that determine the Match outcome in the
algorithm. Nagarkar and Janis (2012) explained that the NRMP strives to promote uniform
guidelines for medical school participants, protecting applicants’ confidentiality and rights.
The Importance of Residency Training
Medical residency training is essential to practice medicine in the United States, and it is
part of the core of medical education that is based on learning from practical and clinical, as
opposed to textbook, experience (Chan et al., 2021). Residency programs allow doctors to gain
specialty-specific clinical applications through training and mentorship, thereby enhancing their
skills in clinical-based settings. The residency learning model established by Dr. Halsted allows
17

physicians to progressively study and gain an understanding of the scientific basis of diseases
through a training hospital program (Grillo, 1999).
Residency Requirements
A medical residency typically begins when a candidate completes medical school.
Depending on the specialty, residents may spend three to eight years working in a training
hospital or clinic learning through on-the-job training (Bingmer et al., 2019; Grillo, 1999). There
are several requirements for applying to residency programs, including the application,
curriculum vitae (CV), three letters of recommendation (i.e., from the Dean of the medical
college, research advisors, or attending physicians during rotations), USMLE board licensing
scores, personal statement, and medical school transcripts containing grades on exams and
overall rank placement within the applicant’s medical school class. For international students, the
Educational Commission for Foreign Medical Graduates (ECFMG) certification is also required
(Stillman et al., 2016). The purpose of ECFMG Certification is to assess whether international
medical school graduates (IMGs) are ready to enter U.S. residency programs that are accredited
by the ACGME (ACGME, 2022; Stillman et al., 2016). If international students do not fulfill all
the requirements for residency, they may have to reapply during another cycle.
During residency, physicians gain additional experience in one chosen medical specialty,
such as Internal Medicine or Emergency Medicine, among others. In the United States, residency
training programs are referred to as graduate medical education (GME) and are accredited by the
ACGME. There are approximately 9,500 residency programs accredited by the ACGME in the
United States (ACGME, 2022). GME institutions typically classify the residents according to
their postgraduate years, such as PGY-1 for their first postgraduate year up to PGY-8 for the
eighth postgraduate year. Importantly, the length of residency depends on the specialty
18

(ACGME, 2022). For instance, family medicine is generally a three-year residency program,
whereas neurosurgery is typically seven to eight-years long. Residents are expected to graduate
from their residency programs and become self-sufficient doctors after passing their Step 3
licensing exams, obtaining board certification.
Board Certification
Board certification is essential in the medical field for the career growth and development
of the individual practitioner (Tankersley et al., 2019). Licensure is granted through state medical
boards and board certifications are unique to specialties and subspecialties. Continuing medical
education (CME) credits vary per state (Abbott et al., 2021). For example, for a cardiology
specialty in California, the Medical Board of California requires 50 CME hours every two years,
whereas, for the same specialty, the Minnesota Board of Medical requires 75 CME every three
years (BoardVitals, 2021). All physicians must be licensed to practice medicine through board
certification. This certification and medical licensure set the standard for minimum competency
requirements that will allow doctors to diagnose and treat patients. Moreover, board certification
in a specific specialty means that the doctor has “exceptional expertise in a particular specialty
and/or subspecialty of medical practice,” according to the American Board of Medical
Specialties (Murphy, 2019). Thus, pathway to self-sufficiency as a certified physicians consists
of a series of interconnected steps, beginning with the medical residency interview, the focus of
this study.
Background of Underrepresented Minorities in Medicine
While the United States only began recognizing the importance of inclusion during the
Civil Rights movement in the 1960s, the true value of diversity in the United States with respect
to individual and group performance was not genuinely understood until decades later (Anand &
19

Winters, 2008). In the 1990s, several businesses realized that incorporating diversity into
company culture and strategy improved problem-solving ability and employee retention and
engagement, profitability and overall business success (Anand & Winters, 2008). In healthcare, it
has been argued that the value of diversity remains less researched although increasingly
accepted and prioritized (Rosenkranz et al., 2021). Importantly, diversity in medicine contributes
to improved medical outcomes, as patients feel greater satisfaction when cared for by providers
who share similar language, ethnic, and racial identities (Chen et al., 2005; Chin et al., 2012).
The racial composition of medical faculty and medical students has slowly changed over time, as
diversity has been integrated into the overall mission statement in medical programs (Coe et al.,
2020).
In 2019, Black and Latinx physicians each comprised only 5% and 5.8% of the U.S.
physicians, respectively (Usoro et al., 2021). It has been demonstrated that physicians who share
the same background as their patients are more likely to treat underserved minority patients
conventionally, but despite the rapid growth and diversification of the U.S. population, there has
not been a significant increase in diversity among physicians (Aibana et al., 2019). Evidence
suggests that patients who consult physicians with similar characteristics are more likely to
pursue preventative care, spend more time with their doctors, and report high levels of
satisfaction with their care (Liebschutz et al., 2006). Therefore, to reduce health disparities seen
in minority populations, measures must be taken to advance health equity throughout the nation.
Health equity likely begins with training more minority physicians who know the characteristics
and qualities of the marginalized communities they serve.
The AAMC estimates that by 2032, the United States will see a physician shortage of
over 120,000 doctors (AMSNY, 2020). Previous studies have shown that physicians from
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minority backgrounds are more likely to practice primary care and practice in underserved areas
(AMSNY, 2020). Thus, embracing diversity can increase medical care in underrepresented
communities, improve familiarity with cultural differences in patients, and support ongoing
research into health care disparities (Frierson, 1987; Liebschutz et al., 2006). Through outreach
programs for underserved communities, a diverse healthcare workforce can improve patient
relationships.
While the new 2009 accreditation guidelines have improved diversity among medical
students, there are still significant disparities in the physician workforce (Khan et al., 2019). The
Liaison Committee on Medical Education (LCME) changed its mission statement regarding
diversity in 2009 and stated that all medical schools are required to create programs that are
geared toward broadening diversity among qualified applicants for admission (Barzansky et al.,
2021). A large part of the representation deficit may be due to several systemic barriers that
prevent minority students from pursuing careers in medicine. The largest barriers to URiM
recruitment and enrollment were the following: (a) Medical College Admission Test (MCAT)
scores (90%), (b) lack of minority faculty (71%), and (c) a lack of minority role models (71%)
(Agrawal et al., 2005). In addition, some students also mentioned financial burden as a barrier
(Agrawal et al., 2005). It is critical to aid and foster diversity in medical school to help students
prepare for their roles as professionals in diverse communities (Komaromy et al., 1996).
The ACGME recently updated its common program requirements for residency and
fellowship programs. According to Usoro et al. (2021), increasing the URiM pipeline into GME
training programs will help support the recruitment and retention of URiM in medical school and
during GME training. According to Clayborne et al. (2021), URiM students are more likely to
have lower medical scores; however, lower standardized test scores do not necessarily correlate
21

with professional performance. Clayborne et al. (2021) used a structured tool to determine the
clinical skills of incoming residents and found no difference in performance between URiM and
non-URiM residents. Thus, medical schools and training programs should remove these barriers
to help improve diversity for candidates through the pipeline, to include providing equitable
opportunities for URiM physicians to excel during the medical residency interview process.
Factors Contributing to Lack of Diversity in Medical Education
This study aimed to understand whether different residency interview modalities served
as barriers to URiM residency applicants. Diversity in the workplace and in education is also
regarded as a critical component of social fairness. Diversity can be defined as the “inclusion of
varied attributes or characteristics” (Togioka et al., 2022, p. 1). Togioka et al. (2022) described
that the “inclusion of healthcare professionals, trainees, educators, researchers, and patients of
varied race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation,
gender identity, primary spoken language, and the geographic region” (Togioka et al., 2022, p.
1).
It is becoming increasingly essential to attain a more diverse physician population to
improve patient outcomes and the health of society. A thorough understanding of how URiM
physicians influence health care and education is imperative to helping institutions develop
pipeline programs and practices that effectively increase diversity in medical schools, hospitals,
and communities (Clayborne et al., 2021). According to Clayborne et al. (2021), research
elucidates four focus areas to increase the diversity of URiM. The first is by understanding the
role academic medicine plays in the process of underserved physicians. The second is reviewing
the direct correlation between the professional identities of physicians and their academic
programs. The third is to understand the importance of having URiM from marginalized
22

backgrounds in the community. Lastly, increasing the number of diversifying physicians can
help eliminate the health care disparities.
Phelan et al. (2019) surveyed 4000 medical students to evaluate their intention to practice
in an underserved area. The results showed that medical students were more likely to practice in
underserved areas if their medical school program had a steady commitment to diversity in the
curriculum. In a baseline survey, 22.8% of students indicated their intentions to work in an
underserved community, with 16.3% specifically intending to work with minorities. In a follow-
up survey, 62.5% remained undecided about working in underserved communities, and 59.9%
remained undecided about working with minorities. However, results also showed that 30.9% of
survey respondents lost their intention to work in underserved communities, and 33.2% lost their
intention to work with minority populations. Phelan et al. (2019) concluded that their study
shows evidence of racism at multiple levels in medical schools and is correlated to graduating
students' decisions to serve in needed communities. There are several factors that contribute to
the lack of diversity in medical education such as lack of diverse faculty, lack of mentorship, and
overall implicit bias and microaggression, each of which will now be discussed in turn.
Causes of Lack of Diverse Faculty in Medical Programs
Lack of diverse faculty in medical residency programs can negatively influence URiM
physicians. According to Campbell and Rodríguez (2019), clinical faculty and leadership are not
at optimal diversity at medical institutions. Addressing this problem is important because
increasing physician diversity often increases the number of physicians serving underrepresented
populations (Metz, 2017). Page et al. (2011) conducted a cross-sectional survey to examine
diversity program leaders at United States MD-granting medical schools. The researchers
measured African American and Latinx faculty representation, finding that only 3.0% and 4.2%
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of diversity program leaders were African American or Latinx, respectively. Thus, diversity
leadership may be a component of the problem, as URiM medical students and residents reported
higher levels of satisfaction in rotations containing URiM faculty (Gutierrez-Wu et al., 2022).
One factor that contributes to the lack of diversity in medicine is the lack of minority
faculty to advocate for minority students (Chung & Armitage-Chan, 2022). Most literature on
this topic focuses on faculty experiences in general, considering the effects of race, diversity, and
gender, but there is a gap in the literature about the specific experiences of minority faculty in
higher education and how this is affected by pervasive derogatory stereotypes (Madrigal et al.,
2021). While historically Black colleges and universities have long fought against stigmatization
and acted as examples of minority excellence, it remains critical to actively acknowledge the
significance of minority faculty members in higher education as being important role models in
counteracting negative biases and as having a lived experience that is affected by their race (Ford
& Airhihenbuwa, 2010; Mahmud & Gagnon, 2020).
Mahoney et al. (2008) reviewed the experiences and perceptions of minority faculty at a
university regarding racial diversity in medicine. Minority faculty play an essential role in
improving URiM student performance. The authors concluded that minority faculty are valuable
resources to consult regarding the implementation of diversity in academic medicine. The
participants in the survey emphasized the important and strong correlation between effective
mentorship and success. Moreover, the findings affirm the need for minority faculty to advocate
for the recruitment and retention of URiM students. Despite efforts toward increasing diversity in
medical education, minority instructors still only comprise a small percentage of all active
medical teachers in the United States (Dady et al., 2021). This is unfortunate, as minority faculty
members have been shown to act as critical role models to all students, but especially to Black
24

students (Chin-Hong et al., 2020). According to Chin-Hong et al. (2020), average test scores are
higher in classes with minority instructors, and students show increased discipline. The lack of
culturally sensitive diverse education may also contribute to gaps for minorities. Many medical
programs do not offer specific programs or interventions for URiM students (Dady et al., 2021).
Therefore, it is critical to have diverse faculty and staff to advocate in academic medicine and to
increase the representation and exposure of minority students to role models (Page et al., 2011;
Peterson et al., 2004).
The lack of diversity among faculty in academic medical institutions can be detrimental
to minority medical students (Page et al., 2011). As an example, the underrepresentation of a
diverse group can promote feelings of isolation within the academic community, which may lead
to more conscious and subconscious bias (Wesson et al., 2006). In addition, URiM academic
faculty are promoted at decreased rates and have reported feelings of isolation and lower career
satisfaction (Cohen, 1998; Fang et al., 2000). To diversify the faculty in medicine, many schools
have designed diversity programs to assist with pipeline challenges and thereby improve racial
and ethnic minority faculty retention, and recruitment (Fang et al., 2000). Notably, URiM
medical students reported higher levels of satisfaction when provided opportunities to interact
with minority medical educators (Blanchard et al., 2022).
The disproportionate representation of minority medical faculty may also have a negative
influence on the likelihood of minority students providing services to underserved communities.
Garcia et al. (2018) evaluated the factors that correlated with medical school graduates’ intention
to serve underserved populations. Garcia et al. (2018) postulated that if the faculty pipeline is
diversified, serving underrepresented communities may contribute more prominently to the
mission. The authors also stressed the importance of how minority faculty bring another layer of
25

inclusivity to a social mission of helping medically underserved populations. Garcia et al. (2018)
discussed of the necessity of incentive programs to diversify the faculty as incentivizing
leadership development for future physicians. Thus, these organizational missions for achieving
health equity for underserved populations can help improve diversity within the field of medicine
through cultural competence and diversity, equity, and inclusion (DEI) (Channaoui et al., 2020;
Hunt et al., 2015; Lightfoote et al., 2016). Cultural competence involves equality and
acknowledges historical injustice whereas structural competence focuses on the elements of
health influenced by policy (Francis & Villwock, 2020; Wolf et al., 2020; J. Young & Young,
2018).
Kohli et al. (2019) mentioned that schools in ethnically diverse societies need leaders and
leadership models that address the racial, cultural, and ethnic composition of the school
community. This can start as early as K–12 because this is a critical period for social
transformation and improving strategies for diversity and inclusion (Duncan, 2002; Kohli et al.,
2019). Having a more diverse academic community might help to develop better outreach
programs in which students can relate to the faculty (Duncan, 2002). There are several ways to
improve diversity in medicine. Changing policies and administrative processes may encourage
residency program admissions officers to consider a similar review process, thereby removing
the false perception that increasing diversity means lowering admission standards (Francis &
Villwock, 2020). In addition, developing mentorship programs that help underserved
communities and speak directly with students about their work as resident doctors is important.
Such programs will also address lingering unconscious biases and daily cues, which can be
problematic for retaining talented minorities in medicine (Francis & Villwock, 2020). Lack of
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faculty diversity in medical programs is linked to the next factor that influences diversity in
medicine, namely the lack of mentoring opportunities for URiM physicians.
Lack of Mentoring, Recruitment, and Retention of URiM
Mentorship is a critical component of residency programs, with medical residents
choosing mentorship opportunities as a leading reason for their choice of residency programs
(Borges et al., 2010). Medicine contains a disproportionately low number of URiM physicians,
suggesting that mentorship programs for medical students may not be guided by URiM faculty.
Therefore, there is a need to focus on ways to retain and improve the experiences of URiM
physicians and trainees through mentorship opportunities. Studies have shown that an important
factor contributing to the lack of diversity in medicine is the lack of mentoring opportunities,
creating educational barriers. Bright et al. (1998) examined barriers to the medical education
experience by surveying fourth-year medical students. The study aimed to understand the
psychosocial and psycho-emotional aspects of medical education through the lens of race or
gender. Women reported that the lack of mentorship was a large barrier to academic success in
medicine (27%) (Bright et al., 1998). In addition, underrepresented minorities mentioned they
felt as if they were required to be twice as proficient to be treated as equal to their counterparts
(52%). Moreover, 23% and 40% of the underrepresented minority students mentioned that the
lack of a same-race mentor and role model, respectively, were barriers to their medical education
(Bright et al., 1998). The present study is important because it seeks to disclose some perceived
barriers and biases that are seen in medical education, particularly in the medical residency
interview process, which can setback the professional development of minority and female
students. The lack of mentors and role models can be addressed by making conscientious
27

decisions to recruit, hire and retain more underrepresented minority faculty members (Bright et
al., 1998; Modan, 2021).
Bonifacino et al. (2021) performed a systematic review to observe mentoring programs
for URiM physicians in medicine to recognize and describe mentoring programs for URiM
physicians. The study findings suggested that mentoring programs should consist of institutional
support for diversity, and personalizing programs for URiMs, as this will effectively enhance the
number of and success of URiM physicians across medical specialties (Bonifacino et al., 2021).
Bonifacino et al. (2021) also described that the “cascading model of mentorship” allowed for the
“amplification” of the reach of faculty and URiM medical students (p. 3). This study is
noteworthy because it can be used and adapted for institutions that have a limited number of
available faculty mentors. Tailoring mentorship programs and resources can be carefully
designed per minority group. Mentorship may also be critical for URiM physicians as they
prepare for and complete their medical residency interviews (Moreno et al., 2020). Thus,
institutional support that fosters a climate of inclusivity encourages faculty enlistment and
retention (Martinez-Acosta & Favero, 2018), facilitating mentorship opportunities for URiM
physicians at critical junctures in their careers.
Implicit Bias and Microaggressions Experienced by URiM
This study examined potential implicit bias and microaggressions experienced by URiM
physicians during their medical residency interviews. Microaggressions and structural racism are
rooted in societal, historical, and cultural norms, affecting racial group inequality (Togioka et al.,
2022). Like any other sector and field, medicine needs practices and policies that address
unconscious and conscious structural racism. Togioka et al. (2022) also mentioned that at a
systems level, artificial intelligence may contribute to the lack of diversity in medicine. Medical
28

implications of racism and access to care could occur on a structural level that promotes health
disparities. An example of this is an algorithmic bias that was identified in a medical artificial
intelligence program. It is noteworthy to mention that these algorithms may also play a role in
admission into colleges or medical programs (Togioka et al., 2022).
Structural racism notwithstanding, conscious and unconscious microaggressions may
contribute to the attrition of URiM. Cruz et al. (2019) used the psychometric Microaggressions in
Health Care Scale to evaluate perceived racial microaggressions and discrimination in over 250
African American and Latinx respondents. The participants in the study were assessed based on
healthcare microaggressions and daily discrimination (Cruz et al., 2019). The results of the study
showed that microaggressions positively correlated with reports of perceived discrimination,
suggesting that microaggressions can be a significant risk to the quality of life for URiM
physicians (Cruz et al., 2019). This study confirms that minorities are at risk of facing multiple
forms of discrimination in the medical field (Cruz et al., 2019).
In this second section of the literature review, I discussed the background of URiM in
medicine. This discussion included three factors that hinder the recruitment and retention of
URiM physicians: (a) lack of retention of minority faculty members, (b lack of mentorship of
URiM, and (c) implicit bias and. Lack of minority faculty members and mentorship opportunities
may influence URiM physicians’ preparation for their residency interviews, the focus of this
study. In the next section of the review, I discuss the role of academic medicine in cultivating
URiM physicians.
Role of Academic Medicine in Developing URiM Physicians
The professional identity of physicians is developed through training, teaching, and
overall behavioral responses. Shahabi et al. (2020) described the medical professional identity as
29

how a person perceives themselves as a physician. The professional identity is also based on
socialization through social learning, attitudes, and values (Shahabi et al., 2020). A physician’s
professional identity develops during their residency training (Sawatsky et al., 2020). The
residency interview is the gateway to this training. Key to this discussion is the role of social
learning and attitudes, which are crucial factors in subconscious and unconscious racism.
Racial Discrimination in Academic Medicine
Racial discrimination affects the medical field at different levels. Institutional racism can
influence access to health services, whereas cultural racism can create negative racial stereotypes
(Cobbinah & Lewis, 2018). In addition, interpersonal racism occurs when there is persistent
racial prejudice that affects the doctor-patient relationship (D. R. Williams & Mohammed, 2009).
It is important for racism to be addressed using an interdisciplinary approach through public
health interventions (Cobbinah & Lewis, 2018).
Healthcare Disparities Among Marginalized Groups
Health disparities encompassing health differences based on race, ethnicity, gender, and
socioeconomic status exist across several dimensions (Jackson et al., 2016; Silberholz et al.,
2017). According to Healthy People (2020), the definition of health disparity is:
a particular type of health difference that is closely linked with economic, social, or
environmental disadvantage. Health disparities adversely affect groups of people who
have systematically experienced greater social or economic obstacles to health based on
their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health;
cognitive, sensory, or physical disability; sexual orientation or gender identity;
geographic location; or other characteristics historically linked to discrimination or
exclusion (p. 1).
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Braveman (2014) ascertained that social and economic disadvantages influence how
people are treated in the medical field. Health equity is an important principle that must be
addressed to reduce and eliminate health disparities (Braveman, 2014). Jackson et al. (2016)
found that health disparities exist based on race, ethnicity, gender, and socioeconomic status,
among other categories. The study examined disparities for Black men from low socioeconomic
status compared to White men from high socioeconomic backgrounds, finding significant
differences in mental health, incarceration, employment, and wages (Jackson et al., 2016). The
results showed striking health disparities exist in minority and low socioeconomic populations
(Jackson et al., 2016).
Other studies also examined the prevalence of health care disparities. For example, D. R.
Williams et al. (2012) used a lung cancer case study to focus on researching patterns emerging
when race, ethnicity, socioeconomic status, and gender are integrated into health care disparities.
Gender, socioeconomic status, and race were considered predictors of variations in health
disparities (D. R. Williams et al., 2012). The results showed that social variations in health and
lung cancer risks were shaped by social processes rather than biological ones (D. R. Williams et
al., 2012). Moreover, the results indicated an intersection between all these factors; as such, it is
important to note that race, gender, and status are all interdependent (D. R. Williams et al.,
2012). It is recommended that approaches to treatment considering intersectionality are needed
to address health disparities.
Implicit Bias and Microaggressions within Medicine
This study examines the prevalence and type of microaggressions experienced by URiM
physicians during their medical residency and fellowship interviews. Microaggressions can
affect an individual’s access to resources and opportunities and contribute to the persistent
31

disparities faced by marginalized groups (Ehie et al., 2021; Overland et al., 2019). Torres et al.
(2019) categorized microaggressions as microassaults, microinsults, and micro-invalidations,
which are indirect expressions of prejudice. While microaggression, combined with implicit bias,
can be detrimental to targeted communities, both phenomena are common in the medical field
(Torres et al., 2019). Patients experience this form of racism through systematic dismissal of
pathological symptoms, inferior medical care, and less aggressive preventative treatment (Turner
et al., 2021). Increasing awareness regarding implicit biases and microaggressions may assist in
taking the steps needed for systemic change in the medical field.
Microaggressions are experienced not only by patients, but also physicians. For example,
Brown et al. (2021) examined how often emergency medicine providers experience
microaggressions and implicit bias. Overall, 65% of participants reported experiencing
microaggressions. The authors noted that misidentification of doctors as non-clinician staff was
the most common type of microaggression for minorities and women (Brown et al., 2021).
Specifically, more than 50% of female participants reported being mistaken as non-clinician staff
members almost daily. About 75% of participants reported verbal slander with a vulgar term by a
patient (Brown et al., 2021). Brown et al. (2021) concluded that female and minority emergency
URiM physicians experienced bias and microaggressions.
Other studies also indicate that gendered microaggressions are prevalent in medicine. For
instance, Ahmad et al. (2022) investigated assessed the frequency of physicians’ experience of
bias and microaggressions from patients and their association with job satisfaction, burnout,
career impacts, and behavioral changes. The results of over 300 qualitative and quantitative
surveys showed that female doctors experienced a significantly higher frequency of
microaggressions compared to male doctors. In addition, microaggressions were significantly
32

correlated to job satisfaction (p = 0.009), burnout (p = 0.003), career impacts (p < 0.001), and
behavioral change (p < 0.001). Qualitative responses described race also influenced the
frequency of microaggression and. They authors concluded that physicians experience gendered
and racial microaggressions from patients, which, in turn, influence physicians’ overall well-
being (Ahmad et al., 2022).
Implicit bias and racial microaggressions are also present in the early stages of medical
education, a notion of particular importance for the present study. Chisholm et al. (2021)
compared responses of over 200 URiM and non-URiM medical students to the Racial and Ethnic
Microaggressions Scale to assess their experiences of microaggressions during their medical
education. URiM participants had a significantly higher (p < 0.05) likelihood of experiencing
racial microaggressions during medical school. Furthermore, microaggressions and bias
negatively influenced the learning environment, resulting in increased burnout (62%) among
URiM students compared to their non-URiM counterparts (29%) (p < 0.05). Moreover, URiM
students felt they were significantly less likely to receive assistance to address bias and
microaggressions (26% versus 39%, p < 0.05) (Chisholm et al., 2021). Thus, there is a need for
interventions to minimize the impact and frequency of implicit bias and microaggression at all
stages of medicine, including during medical school and residency interviews.
Microaggressions: Impeding Forward Career Progression
Between March 2020 and March 2022, a significant proportion of employees resigned
from their jobs. The two main reasons cited by employees for leaving their employment
positions were that they did not feel appreciated by their organizations or superiors (54%) o that
they did not feel a feeling of belonging (52%) (De Smet et al., 2021). Notably, individuals who
identified as non-White or multiracial were more likely to leave their positions because they did
33

not have a sense of belonging compared to their White colleagues, serving as a sobering
reminder of the injustices experienced by Black workers and other minority groups. (De Smet et
al., 2021). For example, in an article in The New York Times, Public Displays of Resignation:
Saying 'I Quit' Loud and Proud: People are not just leaving their jobs. They are broadcasting it;
Goldberg (2021) interviews people who have left their employment for various reasons. One
individual, Ms. Knighten, a 28-year-old Black woman, reported experiencing sustained
microaggressions at her former place of employment and resigned to open her own
communications company (Goldberg, 2021). Similarly, in a study by Hall and Fields (2015), one
participant, Harrison, a 50-year-old Black male, described a racist denial of microaggression and
colorblindness by an older White employer (Hall & Fields, 2015). Harrison was also consistently
referred to as exotic by employees. Harrison said,
[Microaggressions] make us so furious that we leave our jobs early. They will not let you
go forward. You can't do a crime. You can't go forward. Everywhere I go, and that's over
20 years, I still get held back for the same thing—I try to move on—They won't let you
(Hall & Fields, 2015, p. 12).
In another study by Sethi (2016) on microaggressions in caregiving professions, one participant,
Susan, described her experience. Susan explained that as a Black immigrant, she experienced
overt racism and was a target of racial microaggression from the patients in predominantly White
nursing and retirement homes. Susan explained there she had little recourse to change this
behavior and feared reporting it to her employer. She recounted her interaction with a patient
who did not like Black people and did not want Susan to care for her. Susan resigned from her
position but explained that after years of experiencing microaggressions by patients, she had
little regard for her coworkers and was pessimistic about future improvements. After quitting,
34

she accepted racism as a part of daily life after encountering it at her new place of employment.
Another Black caregiver, Krishna, left her position and sought work as a private aesthetician. As
a result, she saw less racism and had more freedom in selecting her patients and treatment
settings (Sethi, 2016). This study aimed to examine whether racial microaggressions differ
between in-person and virtual medical residency and fellowship interviews, as well as the
perceptions of URiM medical residency applicants regarding racial microaggressions and their
choice of medical residency. This line of inquiry offered insight into whether racial
microaggressions in residency and fellowship interviews were impeding career progression for
URiM physicians.
In-Person Medical Residency Interviews Versus Virtual Interviews
The residency and fellowship interview process provides applicants with the opportunity
to evaluate programs and determines their potential fit for the residency or fellowship program.
During the COVID-19 pandemic, travel restrictions impacted the ability for residency and
fellowship applicants to attend in-person interviews. Thus, residency programs had to adjust to
virtual interviews (Zoorob et al., 2021). There are several pros and cons to both in-person and
virtual interviews. It has been reported that while virtual interviews have drawbacks, applicants
were typically satisfied with the interview experience (Kraft et al., 2022). Moreover, advantages
include cost and time reductions for both applicants and residency programs (Kraft et al., 2022).
Virtual interviews may be the new format in future application cycles.
General Process of Residency Interviews
The general process of the residency or fellowship interview consists of candidates
interacting with residents and faculty through a series of question-and-answer sessions. The
interview provides a chance for the medical program to become familiar with the candidate on a
35

personal level and allows for a review of their personality attributes, communication skills,
perceived commitment to medicine, and evidence of professionalism (Klammer et al., 2019).
Moreover, the interview process has a significant effect on the order of the rank lists of both the
medical program and the candidate (Klammer et al., 2019). The residency applicant typically
prepares by doing a mock interview, answering questions about their activities outside and inside
of medicine, and their overall medical school experience.
In-Person Interview Process
During an in-person interview, applicants visit the residency or fellowship program
campus in person and speaks at length about their personal credentials and experiences that are
applicable to their application (Pourmand et al., 2018). Some teaching hospitals conduct multiple
mini-interviews with faculty members. In-person interviews are the traditional mode of
interviewing medical applicants for residency and fellowship programs. A major positive
consequence of in-person interviewing is the interviewee’s ability to communicate verbally and
non-verbally, which can have an impact on their overall interview experience. There are other
significant advantages to in-person interviews, such as having the opportunity to observe
program didactics, visit hospital locations, and avoiding technical difficulties that can impact the
interview interaction.
Virtual Interviews Process
At the beginning of the COVID-19 pandemic, residency and fellowship interviews
moved from an in-person format to a virtual one. Virtual interviews may lead to a more
geographically diverse mix of applications, as the virtual interview process involves less travel
and reduces the costs of applying to programs. While the actual cost savings may be difficult to
quantify and likely depend on medical specialty, location, and the number of applicants, virtual
36

interviews are cost-effective compared to in-person interviews (Pourmand et al., 2018).
Rajendran and Nadler (2022) mentioned that virtual interviews have the capability to shorten the
overall interview period by eliminating travel time, minimizing disruptions to training programs
and rotations, and improving overall clinical productivity in the interview process. Although
there can be a lack of interpersonal experience with virtual interviewing and recruitment, virtual
interviews, as a hybrid model, have not shown a significant difference in interview outcomes
(Rajendran & Nadler, 2022). Therefore, some advantages to virtual interviews include reduced
costs for applicants and programs, more flexibility in interview dates and times, and minimized
time away from rotations for medical students.
Advantages and Drawbacks of Interview Modalities
In this section, I examine the advantages and drawbacks of virtual and in-person
interview modalities for residency and fellowship applicants. Each interview modality has
associated benefits and disadvantages that should be evaluated by program officers when
determining what type of residency and fellowship interview options to offer candidates.
Advantages of the Virtual Interview Process
During the global pandemic, virtual meetings became a necessity and replaced in-person
interviews, also introducing synchronous virtual online training (AlJhani et al., 2022; Buonpane
et al., 2020; Chatziralli et al., 2021; Rajab et al., 2020). Educational institutions, businesses, and
other services started to use virtual communication platforms. The advantages of virtual over in-
person communication vary among individuals applying to residency programs.
There are several significant advantages to virtual interviews, including (a) reduced cost
for applicants and programs, (b) applicants may be able to attend more interviews due to
flexibility with time and money, (c) minimizing time away from rotations, and (d) increased
37

flexibility for interview dates and times. Multiple studies have shown that virtual interviews are
less expensive and time-consuming for both applicants and program directors and coordinators
(A. D. Geary et al., 2022; Rajendran & Nadler, 2022). Rajendran and Nadler (2022) described
that an advantage of virtual interviews is the shortening of the interview time frame by removing
travel time, reducing interruptions within training programs and clinical productivity. Results
from a survey of residency applicants from the 2020 virtual interview cycle showed that one-
third of candidates saved at least two weeks of time interviewing virtually compared to
interviewing in-person (Kraft et al., 2022). Moreover, applicants reported that virtual interviews
had a positive effect on clinical productivity, personal and family well-being, schedule
flexibility, and reduced financial burdens (Kraft et al., 2022; Pourmand et al., 2018). Eliminating
travel and accommodation costs may influence an applicant's socioeconomic status and ability to
finance interviews during the selection process (Awe & Ai, 2022; Fuchs & Youmans, 2020;
Rajendran & Nadler, 2022). For instance, the Zoom platform can be used by both parties in a
very effective interview style. This face-to-face virtual meeting can be easily scheduled, as travel
time is not a consideration. According to Shah et al. (2012), the expense for an in-person
interview at a urology residency program is over $5,000 per interviewee. However, online
interviews cost approximately $2100. Thus, the financial gains of virtual interviews work in the
favor of both applicants and residency programs.
Moran et al. (2021) reported that most applicants and residency program directors
thought that virtual interviews enhanced the equity of applicants. Some residency applicants may
decline in-person interview invitations due to time constraints, thereby decreasing the number of
programs they can rank (Shah et al., 2012; Vadi et al., 2016). Virtual interviews can assist with
scheduling and time conflicts (Maurer, 2021). Moreover, it was observed that virtual residency
38

interviews decreased the total time dedicated to interviews, enhancing work productivity for staff
and faculty. In addition, virtual interviews allow for more accommodations regarding time zone
differences. Applicants can be offered accommodations for morning, afternoon, or evening
interviews (Pourmand et al., 2018).
The popularity of telehealth recognized during the COVID-19 pandemic may foreshadow
a shift toward medicine, including residency interviews, being conducted virtually. Andrews et
al. (2020) ascertained that patients and providers had high satisfaction levels using telehealth
during the pandemic and reported a high likelihood of adopting telehealth practices in the future.
Thus, adapting residency interviews to a telemedicine format may allow interviewees to
experience residency programs in the telehealth format their programs will use. He et al. (2020)
reported that general synchronous distance education was not significantly different from in-
person learning effectiveness and their findings provide indications for utilizing online remote
education in the future. Mehall (2020) mentioned three types of interactions that are necessary as
a critical element for online educational settings: (a) student-content interaction, (b) student-
student interaction, and (c) student-faculty interaction. These interpersonal interactions can also
be applied to residency interviews. For instance, Porpiglia et al. (2020) mentioned that
interactive audio and video conferencing allow for real-time interaction and with the advent of
telecommunication networks, participants are able to transmit high-quality images giving a
close-to-reality in-person experience.
Heitkamp and Morgan (2021) reviewed the effects of virtual social events offered by
residency programs by allowing candidates to experience the departmental diversity, equity, and
inclusion policies. These virtual social events were equitable residency candidates by allowing
candidates to communicate and connect with programs without the costs of travel. The authors
39

also noted that the relaxed and intimate small group setting helped residency candidates ask
difficult questions and steer the discussion. Thus, the researchers concluded that these virtual
social gatherings allow applicants to explore different virtual domains of equity and inclusion
(Cotner et al., 2022; Davis et al., 2020; Heitkamp & Morgan, 2021).
Virtual interviews may be a way to mitigate bias and microaggressions during the
interview process. For example, Hoi et al. (2022) suggested performing blinded interviews
helped to mitigate microaggression and allowed applicants to speak freely, feel empowered to
ask questions, and allowed them to focus on their strengths without judgment. Walter (2022)
mentioned that virtual interview is not a panacea to the racial disparities present in residency
programs, stressing that virtual interviews can be a tool that equalizes candidates, thereby
increasing racial equity. To summarize, the existing literature shows that virtual interviews show
great promise and will most likely continue to expand throughout medicine.
Advantages of In-Person Interviews
There are several significant advantages to in-person interviews: (a) more interactions
with regard to interpersonal skills, (b) opportunities to observe program didactics and visit
hospital locations, (e) there are no technical difficulties that can impact the interview interaction,
and (f) less misrepresentation and misunderstanding of the residency training environment. In
addition, in-person interviews tend to last longer than virtual interviews, allowing applicants
more opportunities to ask questions (Maurer, 2021). It is also noteworthy to mention that the
interviewer can evaluate candidates’ body language, which may have a positive overall
impression.
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Maurer (2021) mentions that for jobs that require building rapport and strong social
skills, such as doctor-patient relationships, interviewers should prefer meeting the candidates
face-to-face. In addition, the article by Maurer (2021) mentioned:
In-person interviews offer a higher level of engagement. You can read body language
better and get a better sense of someone's interpersonal skills. Interviewing for roles that
require skills demonstrations would also benefit from in-person interaction. There are
numerous tools that help test candidates virtually of course, but it may be best to bring
those people. (p. 1)
In-person interviews may also be beneficial in lacking background bias that might be seen
through online platforms (Maurer, 2021). This bias might create a judgment of an applicant's
ability to effectively deliver a proper video interview or judgment based on the candidate's home
surroundings.
There are some instances that technology cannot replace. Lewis et al. (2017) showed that
most residents who matched completed their interviews on a “didactic day,” with increased
resident and faculty presence. Thus, enhancing presence of faculty and residents could help the
recruitment process by allowing applicants gain insight into the program. Thus, being present
and interacting with residents in-person may help with the rank process.
In-person interviews may facilitate a better social understanding of the residency
program. Bernstein et al. (2020) mentioned that perceived happiness of current residents is one
of the most important factors when creating a rank list. Applicants perceived that they could
interact better during grand rounds and didactics in-person. This advantage of in-person
interviews can help applicants decide if they are a “good fit” for the medical residency program.
Bernstein et al. (2020) also describe another advantage of in-person interviews is that residency
41

applicants have the opportunity to ascertain whether they are comfortable living in that particular
city by touring the hospital, restaurants, parks, and public transportation locations.
Disadvantages of Virtual Interviews
Virtual interviews have some notable disadvantages. Some studies suggest that virtual
interviews may promote bias toward minorities by creating a situation in which they gauge
program inclusivity (Awe & Ai, 2022; Rajendran & Nadler, 2022). Rajendran and Nadler (2022)
made recommendations to mitigate bias, including: (a) sponsor Implicit Association Test training
for the program and committee, (b) use standardized rubrics for interview scores, (e) using a
multiple mini-interview format, (d) using several interviewers or assessors and, (e) have a
diverse representation of candidates during the interview process. In addition, virtual interviews
may have the possibility of introducing unanticipated sources of bias thereby amplifying
disparities (Davis et al., 2020). To obtain the optimal virtual environment, it is necessary to
continuously assess and change the interviewing process (Awe & Ai, 2022; Kakepotoa et al.,
2021).
Virtual interviews, by nature, are prone to technological interruptions. For example,
Maurer (2021) describes how technology can be problematic to virtual interviewing. A senior
manager at a cybersecurity company was quoted as saying the following:
They'll cut out on you, or there are Internet connectivity and bandwidth issues or video
processing issues. You then have candidates being evaluated on the ability to maintain a
video interview, which has nothing to do with the job itself. (Maurer, 2021, p. 1)
Thus, technological issues can hinder an applicant’s experience and subsequent perceptions of
the residency or fellowship program.
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Ashrafzadeh and Nambudiri (2020) mentioned that virtual interviews may create some
obstacles as they are limiting to the residency applicant’s opportunities, including the following:
(a) visiting and touring the programs, (b) interacting with multiple residents and faculty during
the on-campus visit, (c) lacking observation during didactics, and (e) assessing programs' patient
populations. Indeed, a disadvantage of virtual interviews is the inability of applicants to
experience the physical hospital and city setting. Healy and Bedair (2017) mentioned that some
residency applicant who interviewed virtually felt they did not have the opportunity to present
themselves properly or they did not feel comfortable enough to rank the program. Thus, virtual
interview platform may affect the rank list. Even though studies have shown that most applicants
were satisfied with virtual interviews, more research is needed to better understand how virtual
interviews affect the applicant’s rank-order list (Pourmand et al., 2018), an important
contribution that the present study will add to the existing knowledge.
Lessons learned from virtual learning environments may be applicable to the virtual
interview process. Hinds (1999) found that individuals who used video conferencing were more
prone to making mistakes and reported problems with audio conditions, such as picture and
audio latency. Bailenson (2021) ascertained that platforms like Zoom may cause cognitive
overload by sending extra sensory cues. For example, participants are involuntarily forced to
monitor their nonverbal behavior and while sending body language cues. Placing oneself in the
center of the camera’s field of view, exaggeratingly nodding or not looking directly into the
camera may create problems during an online interaction (Bailenson, 2021). In this way, the
constant monitoring of behavior during a Zoom call may lead to cognitive overload. Moreover,
Croes et al. (2019) compared face-to-face video and in-person interactions, noting that people
speak 15% louder on video. Bailenson (2021) also discussed the lack of participant mobility due
43

to the camera’s field of view. When participants are on a Zoom call, they must remain within the
camera frustum to be seen; thus, during an interview, people might shift out of focus, impacting
the overall interview. Porpiglia et al. (2020) argued that human contact is not possible to
reproduce on an online platform and highlight that formal interactions could be at risk while
potentially reducing networking opportunities. Finally, Swan (2001) mentions that in order to
optimally use video interactions, one must have clarity of design, interaction with instructors,
and active discussion regarding the perceived learning.
Disadvantages of In-Person Interviews
In-person interviews also have drawbacks. For example, in-person interviews can be very
costly to both the applicant and programs. Each residency program includes daily meals,
transportation between clinical sites, and staff time dedicated to the interview day, which
amounts to an approximate $2,900 cost difference (Shah et al., 2012). Moreover, in-person
interviews may create problems with scheduling conflicts. Residency applicants may decline
interview invitations due to these conflicts, thereby decreasing the number of programs available
to rank. Limiting travel during the interview process is a tactile way to decrease the postgraduate
program’s carbon footprint (Donahue et al., 2021). Donahue et al. (2021) assessed the carbon
footprint associated with residency interviews, finding less CO2 emissions during the 2020-2021
cycle, which had virtual interviews, than in the 2019 cycle, which had in-person interviews
(Donahue et al., 2021). Thus, the environmental impact of residency interviews should be
concerned as there is a transition to virtual interviews in future cycles. Reforming the residency
interview process may be beneficial regarding the total carbon footprint (Donahue et al., 2021).
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Summary: Pros and Cons of Virtual and In-Person Interviews
The COVID-19 pandemic resulted in residency programs transitioning to virtual
interviews which may, in turn, contribute to new practices in telemedicine that last beyond the
pandemic. Table 1 includes an overview of the pros and cons of virtual and in-person
interviews.

Table 1

Summary of the Pros and Cons of Virtual and In-person Interviews

Interview Type

Advantages

Drawbacks

In-Person

 Applicant gains more
interpersonal experience.
 Opportunity to observe
program didactics.
 Applicant gains a better
understanding of the
residency training
environment

 High costs for interviewee
 High costs for program layout
 Interviewee travel time
 Large carbon footprint
 Scheduling conflicts

Virtual

 Reduced financial costs.
 Decreased environmental
costs
 Time saved
 Better scheduling
flexibility
 Mitigates
microaggressions

 Loss of interpersonal
experience with residents and
faculty
 Risk of technical difficulties
 Lack of participation in
didactics
 Inability to tour the programs

Note. This table demonstrates the positive and negative factors associate with interview types.

45

The ongoing benefits of technology, thus far during the residency application cycle,
ensure that virtual interviews show promise and may help improve disparities for minorities in
medicine. In the future, studies may be conducted to understand and evaluate how the virtual
application cycle affects programs and applicants' decisions. In addition, studies should be
conducted on the incorporation of virtual interviews as a hybrid model, with both in-person and
virtual visits available to residency applicants. CRT is employed to underpin the creation of the
study design by exploring the structural inequalities that create disparities for minorities. Thus,
using CRT will provide a framework to better understand race-equity intersections and serve as a
focal point to create policies within the medical arena.
Strategies for Mitigating Microaggressions and Bias in Interviews
Training employees and interviewers is critical for the mitigation of microaggressions
and bias in any type of interview setting. According to Ackerman-Barger et al. (2021),
microaggressions in academic medicine can be effectively mitigated through employee training
programs that educate employees on recognizing their own biases and prejudices, while also
educating them on different types of microaggressions. Specifically, Ackerman-Barger et al.
(2021) designed a workshop that included a presentation of microaggression theory with seven
cases of microaggressions in the health professions education environment. Pre- and post-
training measurements found statistically significant improvements in participants’ knowledge of
the impact of microaggressions, and self-efficacy in responding to microaggressions, indicating
that physician education is critical for the mitigation of microaggressions in the health sciences.
Notably, Kossek et al. (2022) found that employee training about microaggressions was face-to-
face training regarding microaggressions and inclusion was effective in educating employees on
the importance of inclusion and microaggression allyship awareness and behaviors. These
46

findings are congruent with those of other researchers, who found that interventions aimed at
educating employees effectively reduced microaggressions in the workplace (Smith & Griffiths,
2022).
Creating an inclusive workplace environment is another mechanism for the long-term
mitigation of racial microaggressions in interviews. Research suggests that companies that
promote diversity, equity and inclusion in the workplace have a lesser frequency of
microaggressions in the employee interview process (A. Hinton & Woods, 2018). This may be
especially true in academic medicine, as research suggests that hospitals with strong DEI policies
attract, recruit and retain strong residents and attending physicians (Bersted et al., 2022). Thus,
establishing and maintaining strong DEI policies is a critical first step in promoting an
environment of diversity required for the mitigation of bias and microaggressions in employee
interview settings.
Critical Race Theory
Critical race theory (CRT) provides a framework for exploring race, power, and
infrastructure differences in a variety of different fields. The name critical race theory was
coined from emerging methodologies that extend to principles related to legal racial equity
(Delgado & Stefancic, 2017). CRT theory was first created to explore the intersectionality of
race and power relationships (Delgado & Stefancic, 2017). The widespread application of CRT
has shown that the theory is ideal for considering how large infrastructures and current systems
serve to subjugate and dominate people of color (Delgado & Stefancic, 2017).
CRT is an interdisciplinary race-equity methodology that lies within the social justice
spectrum (Ford & Airhihenbuwa, 2010). Delgado and Stefancic (2017) mention that CRT was
designed to address the movement that took a concern for redressing historic cases such as
47

Brown v. Board of Education and the Civil Rights Movement. Moreover, Delgado and Stefancic
(2017) argued that the creation of CRT was central to ensuring that disparities, systematic
racism, and systematic issues surrounding power and race were discussed and presented to
provide practical and theoretical change. CRT is a social construct that has been used by the
literature to highlight the influence of discrimination on the educational opportunities of people
of color (Delgado & Stefancic, 2017), which will be utilized as a benchmark to frame analysis in
the current study.
There are three constructs that describe the CRT methodology. The first construct is that
racism is ordinary, not aberrational (Delgado & Stefancic, 2017). This construct, however,
mentions that leading powers and ideologies are guided by westernized and White-based ideals.
Thus, discrimination is hard to address because it is so deeply ingrained in society and affects the
infrastructure of society (Delgado & Stefancic, 2017). The second construct is called interest
convergence and material determinism (Delgado & Stefancic, 2017). In this construct, the theory
describes racism and White power structures as only benefiting the White elites in society
(Delgado & Stefancic, 2017). The third construct is the socially constructed nature of racism.
Racism, race, and racial ideologies are based on social thoughts and construction (Delgado &
Stefancic, 2017). Combined, each of these constructs serve to better understand how difficult it
can be to eliminate and reduce racism (Delgado & Stefancic, 2017). Due to the fact that racism is
heavily ingrained within structural and social systems, it is difficult to overcome. Thus, it is
important for researchers to discover ways to create positive social change (Njoku et al., 2017).
The founding tenets of CRT are guided by several ideologies. The core tenets of CRT
include:
48

1. Dominance of White-over-color, as 57.8% of the United States population is White (U.S.
Census Bureau, 2021)
2. Permanence of racism as an inherent part of American culture
3. Ordinariness, which makes racism hard to address.
4. Color-blind perspective that reinforces racial structures and ensures that diversity and
equality are absent throughout society.
5. Interest convergence
6. Critique of liberalism that ignores racist politics that perpetuate social inequality.
Together, each of these tenets allow for a better understanding of how difficult it can be to
eradicate, reduce, or even address racism. In order to remove oppression and help people of
color, society must understand the principles of CRT and address them accordingly (Delgado &
Stefancic, 2017). As racism is ingrained within structural and social systems, it is difficult for the
individual to overcome these by simply acknowledging that racism exists. Instead, it is important
for researchers and practitioners to examine how practice and praxis are met to create positive
social change (Delgado & Stefancic, 2017).
The CRT framework is focused on systematically mending the intersections of racism
and devoting commitment to radically changing discriminatory factors. CRT can be a powerful
tool for targeting racial and ethnic health, as well as educational, and employment inequities.
These founding tenants are used for exploring the modern relationship between race and the
development of structural inequality and the production of disparities (Mkandawire-Valhmu,
2018). The CRT perspective applies to this study due to long-lasting ideologies of ingrained
racism within higher education (Keshet et al., 2015; Pisoni et al., 2019; Uwakonye & Osho,
2012). The CRT theoretical lens can be used to focus on the insight into the intersectionality of
49

systematic and infrastructure issues regarding leadership roles in higher education. There is a
need to examine how to best address these issues through the framework of CRT to consider
practical applications (Reed, 2021). CRT provides a framework that acknowledges racism and
addresses how power structures supported by White ideologies increase disparities among
African American communities (Iversen et al., 2019).
Conceptual Framework
In the present study, CRT will be utilized to understand the relationship between race and
power within the medical residency admission process. Specifically, CRT is employed to frame
this study and underpin the exploration of structural inequalities that create disparities for
minorities in medicine. The theoretical framework is ideal for understanding differences,
barriers, and facilitators for opportunities, with the experiences of URiM at the center of the
exploration. In terms of the current study, the CRT approach is an appropriate framework, as it
explores, based on the experiences of URiM residents in the interview process, the structural
inequalities that reproduce disparities in minorities within leadership roles in medicine and
higher education. CRT is important in the present study because it can serve as a focal point to
examine how policies can be created within the medical sector (Taylor, 2018).
When considering the intersectionality of the CRT framework with respect to URiMs,
there are several important juxtapositions of the population of physicians. The population
comparison highlighted below as an important impact on the URiM medical residency
interviews, as the faculty leadership interviewing URiM is that of the majority, privileged
population. On the one hand is the population of privilege, with individuals who have had access
to the highest caliber of education due, in part, to being from families of high socioeconomic
status with the economic means to provide for private tutors, access to online education and
50

educational resources others may be able to access (Grant & Roberts, 2022; Yeoh, 2019). This
privileged status can lead to racism, sexism, and genderism (Day-Vines et al., 2021). This is
evidenced in systematic literature reviews that demonstrate that racist beliefs, emotions, or
practices among healthcare providers in relation to minority groups (Parades et al., 2014). When
placed in context of URiM and the medical residency interview, healthcare providers in teaching
hospitals are the individuals interviewing potential residents to assess their match with the
institution. Racism, sexism, and genderism have been shown to impact many facets of the
medical education program, including interviews at both the medical school and medical
residency stages (Dao et al., 2022). As such, it stands to reason that racist beliefs, emotions and
practices among healthcare providers may affect interactions with minority medical residents in
the interview process.
On the other hand is the oppressed population, namely the URiM medical residents being
interviewed, physicians who identify as female or their non-biological gender, immigrants, as
well as URiM medical residents from lower socioeconomic status. These physicians often face
obstacles in the interview process stemming from unconscious and subconscious bias (Dao et al.,
2022). Such bias has led the medical community to become more aware of their personal and
organizational biases when choosing prospective medical residents (Dao et al., 2022). A recent
study in the New England Journal of Medicine highlights that minority medical resident
applicants had a variety of racism-based experiences during their residency interviews (Ellis et
al., 2020). These included microaggressions, stereotype threats, tokenism, imposter syndrome
and homophily (Ellis et al., 2020). These experiences had adverse effects on the prospective
medical resident. For example, with respect to tokenism, Black applicants reported feeling as if
they were considered diversity metrics, rather than colleagues, making the applicants less likely
51

to develop an affinity for the residency program (Ellis et al., 2020). Importantly, CRT can be
utilized as a lens to understand how racism in society and in the healthcare, industry impacts
minority medical physicians in the virtual interview process.
Conclusion
The reviewed literature explored current research about the virtual residency interview
process, including whether URiM applicants experienced differences in implicit bias or racial
microaggressions between their virtual and in-person interviews. As part of the first section,
information was presented regarding the importance of residency, factors contributing to a
potential lack of diversity in residency programs, and the professional identities of doctors.
Furthermore, residency programs aim to reduce educational and opportunity gaps between URiM
medical students and residents. Diversifying the physician workforce in the U.S. aligns with
efforts to create pipeline programs within medical education, emphasizing the relationship
between various social identity factors of the URiM. Residency interviews, therefore, can be a
dividing point in the education of a young physician. If a physician receives fair treatment
compared to other candidates, the residency match could be an integrative gateway to the
physician’s career. On the other hand, if a physician is placed at a disadvantage for non-
academic reasons, the residency interview could serve as a barrier to further medical education,
thereby limiting the physician’s future career choices. Thus, implementing strategies that
encompass an intersectionality framework is critical to increasing the number of URiM in the
health profession.
The second portion of this literature review discussed racial discrimination in medicine,
healthcare disparities among marginalized groups, and the implicit bias and microaggressions
present in medicine that is anchored in the CRT framework. An intersectional approach can be
52

used as a foundation for action aimed at reducing health disparities through enhancing ethnic-
gender diversity in health care professions, thereby improving the population’s health (Keshet et
al., 2015). The final section reviewed in-person versus virtual experiences for applicants and
discussed the CRT framework and addressed how racism, gender, and microaggressions affect
the interview experiences of URiM doctors.

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Chapter Three: Methodology
The United States is becoming increasingly diverse, with Black and Latinx comprising
12.6% and 18.9% of the U.S. population, respectively (U.S. Census Bureau, 2021). However, the
percentage of Black and Latinx medical students is disproportionately low, with Black and
Latinx representing only 6.2% and 5.3% of U.S. medical students, respectively (AAMC, 2019).
Many studies have underscored the importance of increasing the number of URiM physicians in
the medical workforce, as having physicians from underrepresented backgrounds increases
physician-patient rapport and has been associated with increased patient satisfaction (Mhyre et
al., 2022) and perceived quality of care (Jetty et al., 2022). Moreover, URiM physicians are more
likely to practice in underserved communities, making this population of physicians an important
gateway to the mitigation of health disparities in the United States (Garcia et al., 2018).
In Chapter Three, I review the purpose and research questions in the study. Next, I
discuss the mixed methodology and why I chose this methodological paradigm for this study.
The chapter will then include a discussion of the research design that I utilize for this
methodological study. Next, I discuss my positionality as a researcher and highlight the
reflexivity protocols I undertake during the study to mitigate researcher bias. Next, I discuss the
data sources for each research question, including the participants, instrumentation, and data
collection procedures that I use to answer each research question. The chapter then turns towards
a discussion of data analysis procedures I use in the study. Finally, I discuss aspects of
trustworthiness, reliability, and validity for the study, as well as ethical considerations.
Research Questions
The purpose of this study was to examine the experiences of URiMs who participated in-
person versus virtual interviews at MMC, a teaching hospital in the western United States, in
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order to determine whether there are patterned differences that may provide a disadvantage for
residency URiM applicants from URiM backgrounds. This dissertation aimed to distinguish how
in-person and virtual interviews differentially influence the recruitment and selection process of
URiMs and make recommendations to improve strategies in increasing diversity within graduate
medical education. Three research questions guided this study:
1. Are there any differences in URiM residency and fellowship applicants’ experiences of
bias and microaggressions based on whether they interviewed in-person or virtually?
2. How, if at all, do URiM residency and fellowship applicants experience implicit bias and
microaggressions in the interview process?
3. Is there a difference in the percent of URiMs receiving a residency or fellowship offer
based on whether they interviewed in-person or virtually?
Overview of Methodology
I chose a mixed methodological research tradition for the study. Mixed methods research
has become increasingly popular in a variety of academic disciplines for generating insights that
are not accessible by either the qualitative or quantitative research designs alone (J. Creswell &
Poth, 2018; J. W. Creswell & Plano Clark, 2018; Shannon-Baker, 2022). Mixed methodology
includes the collection, analysis, and integration of the two forms of data and results, framed by
theoretical or conceptual frameworks, as well as philosophy (J. Creswell & Poth, 2018). There
are three general types of mixed methods research designs: sequential explanatory, sequential
exploratory and convergent (J. Creswell & Poth, 2018). Sequential explanatory and sequential
exploratory designs occur in two phases. In a sequential explanatory design, the first phase is the
collection of the quantitative data, followed by a second phase in which qualitative data is
collected (J. W. Creswell & Plano Clark, 2018). Importantly, the qualitative phase seeks to
55

explain or expand on the quantitative result (J. Creswell & Poth, 2018; Winston & Dirette,
2022). Conversely, sequential exploratory designs first prioritize the qualitative phase first to
explore a topic. In the second phase, the researcher designs a “quantitative feature based on the
qualitative results” (J. W. Creswell & Plano Clark, 2018, p. 67). After data is collected from both
phases, the researcher then interprets and connects the results from the two data sets (Winston &
Dirette, 2022). In the convergent design, the researcher collects qualitative and quantitative data
simultaneously, but analyzes each data set separately. After data analysis is completed, the
researcher then determines how to best merge the qualitative and quantitative data to reveal new
information about the phenomenon under investigation (J. Creswell & Poth, 2018).
The nature of the medical residency interview and application process limits the study to
a mixture of convergent and sequential exploratory research designs to form a comprehensive
multistage mixed methods framework. In a multistage mixed methods framework, researchers
utilize multiple stages of data collection that may include various combinations of exploratory
sequential, explanatory sequential and convergent approaches (Nastasi et al., 2007). I used a
published quantitative survey, the Racial Microaggressions Scale (RMAS) (Torres-Harding et
al., 2012), to assess microaggressions experienced by applicants during medical residency
interviews. URiM residency and fellowship applicants who agree to participate in the study were
given the RMAS after completion of their medical residency interview. Concurrent with this data
collection instrument, I also performed semi-structured interviews with URiM medical residency
and fellowship applicants to assess their perceptions of the differences in the presence of implicit
bias and microaggressions in either their virtual or in-person interviews. This convergent design
had two parts. First, any URiM applicants interested in participating in the study were asked to
anonymously complete the RMAS survey, which included a question asking if they would like to
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participate in the semi-structured interviews. Next, URiM applicants interested in being
interviewed participated in the semi-structured interviews. This data collection occurred in the
span of time from November 2022 through March 2023, which corresponded to the timeframe in
which the medical residency interviews occured. As such, data collection via RMAS surveys and
semi-structured interviews was collected concurrently. However, Research Question 3 was
addressed using artifact analysis of hospital-wide data to determine if there were differences in
the matching rate of URiM residency applicants who interviewed virtually or in-person. Data
collection for the RQ3 began until after Match Day, which was March 17, 2023. Taken together,
this suggests that a multistage mixed methods framework was the most appropriate approach
research design for this study.
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Table 2

Data Sources

Research questions

Artifact
analysis

Semi-structured
interviews

Survey

RQ1: Are there any differences
in URiMs residency and
fellowship applicants’
experiences of bias and
microaggressions based on
whether they interviewed in-
person or virtually?

X

X

RQ2: How, if at all, do URiM
residency and fellowship
applicants experience
implicit bias and
microaggressions in the
interview process?

X

X

RQ3: Is there a difference in
the percent of URiMs
receiving a residency or
fellowship offer based on
whether they interviewed in-
person or virtually?

X

The Researcher
The integrity of qualitative research depends on the skills, competence, and thoroughness
of the individual conducting the research. In the present convergent mixed methods research
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study, when it comes to the qualitative aspects of the design, I, the researcher, was the sole
human instrument, collecting human data analysis, and acting as an objective viewer (Wa-
Mbaleka, 2018). When working with human subjects, researchers must follow ethical norms by
guaranteeing pseudonymity, voluntary participation, and a thorough knowledge of the
requirements of the study (Moustaka, 1994). As the sole research instrument, I selected
participants that met the inclusion criteria; administered the chosen implicit bias and
microaggressions survey and conducted statistical analysis; ensured participants' data were
protected; limited researcher bias; interpreted the responses of participants, minimized any bias
or predetermined viewpoints; analyzed the semi-structured interview data using NVivo version
12, a computer-assisted qualitative data analysis software; analyzed the survey-based data and
perform statistical analysis using the R statistical analysis software; and made suppositions
grounded on the emerging themes from the data within the context of the theoretical framework
chosen for the study.
It must be disclosed that at the time of the study, I was currently employed as the Director
of Graduate Medical Education at the teaching hospital in which I performed the study. As such,
I had professional knowledge about the phenomenon under investigation in the research study,
but only as an outside observer of the medical residency application process. As an active
member of the medical residency community, I have a desire to understand the diversity of the
practices of our teaching hospital and I similarly have a desire to increase the diversity of our
graduate medical education program.
Due to my position, there was a potential ethical conflict of interest. Regardless of cycle
year, I only have contact with medical residents after they have been admitted to the program. I
do not have any influence over which medical residency applicants are offered interviews, nor do
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I have any influence over the decision to offer a particular applicant a residency match.
Consequently, I did not encounter any situation in which a participant is my subordinate or a
superior. A URiM physician’s decision to participate or not to participate in the research study
did not influence whether they were offered a residency match. However, to avoid a potential
conflict of interest, the University of Southern California’s Institutional Review Board
determined that any outside, independent interviewer should interview the residency candidates
and anonymize the data prior to delivering it for data analysis.
To mitigate potential researcher bias, I engaged in reflexivity practices throughout the
course of the study. Reflexivity involves a researcher thinking critically about how their values,
opinions, thoughts, beliefs, and worldviews influence each facet of the research process,
including decision-making, data collection, data analysis and data interpretation (Olaghere,
2022). I utilized journaling and memoing techniques to maintain a complete awareness of my
own thoughts, opinions, and beliefs throughout the research process (McGrath, 2021). To this
end, I journaled before and after engaging in any research-based activity, including participant
selection, development of the interview protocol, and data analysis. Similarly, I used memos
throughout the data collection and analysis process. In summary, I used journaling and memos as
reflexivity protocols to mitigate researcher bias.
Data Sources
There were three data sources in this convergent mixed methodological research study,
employed in the following order. First, I asked all participants who identify as URiM on their
residency or fellowship applications to complete a RMAS survey (Appendix A). Included with
the RMAS survey were questions regarding the ethnicity and gender of the participants, and
whether the residency candidate completed their interviews in person or virtually, as these are
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the key variables required to run the proposed analysis. These demographic questions, as well as
a question asking participants whether they would be interested in participating in an interview
for my dissertation, were included in the RMAS survey. A sample of the participants who
complete the survey and indicate interest in participating in an interview were to participate in
semi-structured open-ended interviews (Appendix B). Specifically, I aimed to interview at least
ten URiM physicians. Lastly, statistical analysis of residency and fellowship match results using
hospital-wide data was utilized to determine if there were a statistical difference in whether
URiM physicians interviewing virtually, or in-person were offered residency matches.
Method 1: Survey
I chose a microaggressions survey called the Racial Microaggressions Scale (RMAS), a
self-report inventory with high correlation to measures of discrimination in daily interactions
(Torres-Harding et al., 2012). In the construction of the 35-statement scale, Torres-Harding et al.
(2012) identified six factors for racial microaggressions: (a) invisibility, (b) criminality, (c) low-
achieving or undesirable culture, (d) sexualization, (e) foreigner or not belonging, and (f)
environmental invalidations. The RMAS scale has a high internal validity, which will be
discussed in the reliability and validity section of this chapter and has been shown to be a valid
measure of racial microaggressions (Torres-Harding et al., 2012).
Participants
The general population of the study was URiM medical resident and fellowship applicants in
the United States, whereas the target population was URiM medical residents and fellowship
applicants at MMC, a teaching hospital in the western United States. There are two types of
sampling methods that can be utilized to recruit participants to a study: probability sampling,
which is also called random sampling, and non-probability sampling, or non-random sampling
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(Sedgwick, 2013). I recruited participants through convenience sampling, a type of non-random
sampling. Convenience sampling involves choosing participants that are conveniently available
and easily accessible (Sedgwick, 2013). The selected URiM medical residency applicants
applied to residency programs in family medicine, internal medicine, or emergency medicine.
The selected URiM fellowship applicants applied to fellowships in pulmonary disease, geriatric
medicine, infectious disease, sports medicine, or addition medicine. As the Director of Graduate
Medical Education for a residency program, I had access to data regarding the medical residency
and fellowship applicants. However, as a researcher, I was required to request permission from
MMC to use my access to the data for research purposes. With the appropriate permissions in
place, I extended invitations to all URiM medical residency and fellowship applicants at MMC
after the potential participants completed their medical residency or fellowship interviews. A key
question included with the RMAS survey asked participants whether they completed their
interview in-person or virtually. As such, the conveniently sampled participants must have met
the following inclusion criteria:
1. Participants who are medical residency applicants must be completing medical school or
be in their fourth year of medical school; participants who are fellowship applicants must
be in the final stages of completing their residency program.
2. Participants must be over the age of 18.
3. Participants must identify themselves as URiM on their medical residency or fellowship
application.
4. Participants must be applying to the chosen teaching hospital for residency or fellowship
in the above-mentioned medical specialties.
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I used convenience sampling to select participants meeting the inclusion criteria of the
study. Convenience sampling is a type of non-probability sampling in which members of the
target population are selected for the study if they meet certain practical criteria, including
geographical proximity, availability at a certain time, easy accessibility, or the willingness to
volunteer (Farrokhi & Mahmoudi-Hamidabad, 2012). Convenience sampling allows for the
selection of participants that are convenient and easily accessible (Sedgwick, 2013). Sample
members were not randomly chosen from the population of all URiM medical residency or
fellowship applicants. Instead, the participants must meet the inclusion criteria regarding
applying to specific medical residency and fellowship programs at MMC. Convenience sampling
is an affordable method of sampling subjects that are readily available. Convenience sampling
has important implications for the external and internal validity of a study, which will be
discussed in further detail in the reliability and validity section of this chapter. Importantly, the
main assumption associated with convenience sampling is that the members of the target
population are homogeneous (Etikan et al., 2016). That is, an assumption of convenience
sampling is that there would be no difference in the research results obtained from a random
sample, a convenience sample, or a sample gathered in some inaccessible part of the population
(Etikan et al., 2016).
Instrumentation
I converted the RMAS as published by Torres-Harding et al. (2012) into a survey to send
to participants using the Qualtrics data analysis software (Healthcare Bluebook, 2022). The
RMAS was relevant to the research study because completion of the survey allowed for analysis
of Research Questions 1 and 2, namely how URiM residency and fellowship applicants
experience microaggressions in the interview process and whether those experiences differ based
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on in-person or virtual interview experiences. The survey was generated using Qualtrics, which
allowed me to easily email the survey to participants and collect survey responses.
Data Collection Procedures
Candidates were screened by analysis of their medical residency or fellowship
application at MMC, with permission from the hospital CEO and President. By hospital
permission, these data were available to me as the Director of Graduate Medical Education at
MMC. Potential participants were notified when they submitted their applications that their
contact information may be used for research purposes. Participants meeting the inclusion
criteria were recruited by email using a flier describing the purpose and inclusion criteria of the
study, the expectations for participation and the significance of the study (Appendix C).
Candidates interested in participating in the study were instructed by the flier to email me to
express their interest. Upon receiving an email from a potential participant, I provided each
potential participant with the Information Sheet for Exempt Studies (Appendix D).
My reply to the participant’s email contained a link to the RMAS survey provided by
Qualtrics (Appendix A). The RMAS contained 35 statements assessed on a Likert scale. This
survey took the participants approximately seven minutes to complete. In this study, the RMAS
survey was adapted to meet the purpose of the study to understand perceived microaggressions
experienced by URiM medical applicants completing the interview process. As such, some
questions were modified and others were removed (Appendix A), for a total of 30 statements.
The survey was sent to all URiM applicants who interviewed with the program.
Data Analysis
I initially wanted to analyze whether there was a statistical difference between the
perceived microaggressions of URiM medical resident and fellowship applicants based on
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whether the applicants interviewed online or in-person. However, only one participant
responding to the survey completed their residency or fellowship interview in-person at MMC.
All other participants completed their interview virtually. Therefore, it was not possible to assess
Research Question 1 using the data derived from the RMAS data; instead, Research Question 1
was addressed using semi-structured interview data.
The RMAS data allowed for examination of URiM physicians’ experiences based on their
racial identity as either African American, Latinx, or Multiracial. Differences based on
participant’s gender could also be assessed. The hypotheses being tested in the study were:
H
01
: There is no difference in perceived microaggressions between URiM residency and
fellowship applicants based on racial identity.
H
A1
: There are statistically higher perceived microaggressions for Multiracial URiM
residency and fellowship applicants compared to African American or Latinx URiM.
To determine if there was a statistically significant difference between perceived
microaggressions for each of the six factor scores tested on the RMAS between African
American, Latinx and Multiracial URiM residency and fellowship applicants, ANOVA was
performed. To this end, RMAS data for participants belonging to different participant pool was
averaged. Next, ANOVA for comparison of means was performed for each of the six factors to
identify whether there was a statistically significant difference in the perceived microaggressions
of the three groups of survey respondents. For statistically significant ANOVA tests, post-hoc t-
tests were performed to assess pairwise differences among participants.
Validity and Reliability
The first measure of rigor in a quantitative study is reliability or the accuracy of an
instrument. Reliability is the extent to which a research instrument consistently produces the
65

same results if it is used in the same situation on repeated occasions (Heale & Twycross, 2015).
Instrument reliabilities with a Cronbach’s alpha above 0.6 are considered good, and above 0.80
are considered strong. The second measure of rigor in quantitative studies is validity, defined as
the extent to which a concept is accurately measured in a quantitative study (Heale & Twycross,
2015). For example, a survey designed to explore anxiety, but which measures depression would
not be considered a valid instrument.
The reliability and validity of the RMAS instrument were detailed by the survey’s
creators (Torres-Harding et al., 2012). The internal consistency of the six-factor model was
examined by Torres-Harding et al. (2012) using Cronbach’s alphas for a sample size of n = 377
responses. The Cronbach alphas were found to be very good, with Cronbach’s alphas of 0.81,
0.78, 0.83, 0.87, 0.85 and 0.89 for environmental invalidations, foreigner or not belonging,
sexualization, low achieving or undesirable culture, criminality, and invisibility factors,
respectively.
Validity was measured empirically for the LPI using factor analysis (Torres-Harding et
al., 2012). Results from these studies demonstrated that the RMAS is indeed a valid instrument
(Torres-Harding et al., 2012). These data, taken together, suggest that the RMAS instrument is
both reliable and valid; as such, this instrument measured the microaggressions experienced by
medical residency and fellowship applicants. In this study, the RMAS survey was adapted for
use with medical residency and fellowship candidates. Specifically, the language of the questions
was changed from general statements about individuals’ experiences with every day racial
microaggressions to reflect participants’ experiences with their residency interviews. In addition,
some survey questions that could not be adapted to residency interviews were removed. See
Appendix A for an account of the modified RMAS survey questions.
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Method 2: Interviews
The main qualitative instrument in the study was the use of semi-structured interviews to
investigate the perceptions of URiM medical residency and fellowship applicants regarding
perceived microaggressions and implicit bias during their residency or fellowship interviews.
Importantly, implicit bias was a major focus of the semi-structured interviews because the
RMAS only measures microaggressions, not implicit bias.
Participants
Participants who completed the survey were eligible to participate in the semi-structured
interviews. A question on the survey asked participants if they would like to participate in the
interviews. Participants who answer “yes” to this question were considered for the semi-
structured interviews. In particular, I aimed to interview at least ten URiM physicians. Via the
study-specific Information Sheet for Exempt Studies, I gave each participant that affirmatively
responded an overview of this phase of the study via email, including a summary of the
expectations of their participation. In this way, at least ten participants were selected for
interviews. I offered participants an incentive for participating in the semi-structured, one-on-one
interviews. To this end, I purchased $25 Amazon gift certificates for each participant who
successfully completed an interview. The participants were notified by the research flier that they
would receive a gift certificate upon successful completion of the semi-structured interviews.
Instrumentation
The second instrument used in this study was a semi-structured interview comprising key
questions about the participants’ experiences regarding microaggressions and implicit bias in
their medical residency and fellowship interviews. Importantly, semi-structured, interviews were
used to investigate RQ1 and RQ2. While semi-structured interviews were utilized to collect data
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for the research, the open-ended interview questions provided an ordered and logical manner to
conduct an interview and direct the discussion toward data that could help answer the research
questions. I developed the interview protocol and based the interview questions on the study
purpose and problem statement, as well as critical race theory (Appendix B). Since the RMAS
instrument primarily focuses on microaggressions, a major focus on the open-ended interview
questions was on implicit bias. Open-ended interview questions encouraged responses from
participants discussing their experiences with implicit bias and microaggressions in the medical
residency and fellowship interview process, and researchers utilize this technique to speak with
people who are knowledgeable or experienced with a given topic.
Some demographic questions were included within the interview for two reasons. First,
these questions were utilized as a method of triangulation based on information contained within
the participants’ medical residency or fellowship application. Second, these demographic
questions were included to help the interviewer establish a rapport with the participant and
explore and respond to the study objectives within the context of the participants’ views,
thoughts, and emerging themes. Importantly, I ensured that the open-ended questions in the
interview protocol are designed in a manner so that the participants’ answers to the questions
provide rich, deep information about any experiences of the participants with microaggressions
and implicit bias in the medical residency or fellowship interview process.
Data Collection Procedures
When a participant indicated interest in participating in an interview, I emailed them a
link to the independent interviewer’s Calendly to schedule the planned interviews for the
participants at a mutually convenient date and time. One-on-one interviews were conducted via
Zoom, allowing for direct engagement with medical residency and fellowship applicants who
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may experience microaggressions or implicit bias in the medical residency and fellowship
interview process (Rubin & Rubin, 2012). The independent interviewer conducted the interview
sessions, and was responsible for asking open-ended questions, leading the sessions, and seeking
clarification for any parts of the interview that may be misunderstood. Using open-ended
questions ensure that I could consider the views, attitudes, barriers, and experiences of the
participants (McGrath, 2021) especially regarding any perceived microaggressions and implicit
bias in the residency interview process.
Interviews were audio recorded with the consent of the participants. The audio
recordings, in turn, were used to transcribe the data collected. The duration of each interview was
45-60 minutes to allow time for each participant to expand on their ideas; when listening and
watching the interview videos, I utilized journaling to ensure reflexivity and took field notes to
capture essential impressions or changes in tone. Zoom’s transcription capabilities were utilized
to transcribe the interviews. I reviewed the interviews line-by-line to confirm the transcriptions’
validity and accuracy. The transcription was performed using Microsoft Word. All the interviews
were transcribed within a 72-hour period in order to ensure my own familiarity with the
responses. The interview transcriptions were sent to participants for interviewee transcript review
to ensure the accuracy of the transcriptions and any requested changes will be made to ensure
that the participants’ intentions were accurately captured (see Candela, 2019).
Once the interview sessions were complete and the interview transcriptions had been
reviewed by the participants, each audio recording and interview transcript were saved. The
audio files from the interviews with a pseudonym, namely P1, P2, …, and P16. These
pseudonyms were distinct from pseudonyms used to identify the RMAS surveys, as the RMAS
survey data was returned anonymously. Data collection was considered complete when after all
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interview transcripts had been reviewed by the participants and assigned an appropriate
pseudonym.
Data Analysis
Content analysis was used to analyze the transcripts from the semi-structured interviews
because it is a common form of analysis for large amounts of verbal data (Lindgren et al., 2020).
According to Elliott (2018), a researcher must examine the data, identify themes, categorize
themes, and perform the final data analysis to form a cohesive data-based argument in qualitative
data analysis. Data analysis is a methodical approach to working with obtained data, structuring
it, and placing it in manageable pieces that can be analyzed for the identification of themes
(Raskind et al., 2019). The basic goal of the data analysis process is to organize data, look for
patterns, and uncover themes to determine important information related to the research problem
and questions while combining the results in a way that allows the researcher to draw
conclusions (Raskind et al., 2019).
Content analysis was used to find cohesive instances, essential themes, and patterns in the
data acquired from the interviews. Unlike quantitative research, the research used focuses on
allowing a deeper connection and investigation of the phenomenon microaggressions and
implicit bias in in-person and virtual medical residency and fellowship application interviews.
According to Blanco and Rossman (2021), the data analytic process is comprised of seven
phases: (a) organizing the data; (b) immersion of the researcher in the data; (c) generating ideas
for case summaries and possible themes; (d) coding the data; (e) offering interpretations through
analytic memos and connecting the data to previous literature and to the theoretical framework
chosen for the study; (f) searching for alternative understandings of the data; and (g) writing the
formal presentation of the study. I employed each of these steps in the study.
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In analyzing the data, I looked for broad themes and major ideas of the participants. To
aid in the data analysis and thematic coding process, NViVO Version 12 was utilized. All
information was coded and synthesized in conjunction with the appropriate data analysis process,
as described in Merriam and Tisdell (2015). Moreover, J. W. Creswell and Creswell (2018)
stated, “The process of coding involves aggregating the text or visual data into small categories
of information” (p. 184). I conducted the coding process in order to interpret data in smaller
descriptive units. Coding captures significant ideas surrounding the data without losing meaning
(Saldaña, 2021). The next step in the data analysis process was to develop constructs or
categories. The process was done by research question and sub-research question using the
following process: code, sort, synthesize and lastly theorize. Due to having an epistemological
research question that seeks to understand the phenomenon of URiM medical resident
applicants’ perceptions of microaggressions and implicit bias in their residency and fellowship
interviews, the initial coding methods will include descriptive, narrative, and theming
techniques, as suggested by Saldaña (2021).
A list of initial codes was compiled and grouped through developed anchor codes, in a
manner that includes tallying the frequency and generating categories that addressed the research
questions, again following the models of J. W. Creswell and Creswell (2018) and Saldaña
(2021). I sorted the data collected by determining if a group of codes makes reference to a
specific research question or microaggression, determining how many times a specific code is
attached to portions of the data, and lastly determining if there are underlying meanings of the
codes. During the second stage of coding and in accordance with J. W. Creswell and Creswell
(2018), I used a combination of pattern, axial, and focused coding techniques to further identify
71

the themes. Importantly, I used the elements or components of critical race theory to group the
participant’s responses into themes.
Credibility and Trustworthiness
A study is said to be credible when it accurately captures the perspectives of its
participants. According to Morse (2015), the term credibility is similar to internal validity and
refers to a person's views in a qualitative investigation. Participants can trust the findings of
published research because they believe them to be their own. Therefore, this study can be
regarded as credible because the study participants answered honestly, and the recordings were
not altered in any manner to ensure that they truly reflect the participant's experiences (Cilesiz,
2011). One major factor that mitigate threats to credibility is the study design. Importantly, the
convergent mixed methods design was chosen because it presents the participants’ viewpoints in
conjunction with quantitative data, thereby ensuring that the participants’ perceptions are not
overpowered by the researcher’s beliefs. Credibility was also ensured using verbatim quotations
from the participants in the reporting of themes and sub-themes (Daniel, 2019). I addressed
credibility through the use of memoing and journaling so as to ensure and understand the
reflexivity of the researcher and the use of verbatim quotations from the participants.
Interviewee transcript review was another method I used to address the study's credibility
(J. L. Johnson et al., 2020). As described in the data collection procedures section, interviewee
transcript review involved sending the participants a copy of their interview transcript prior to
data analysis to ensure that the interview transcript accurately reflects the research subjects'
attitudes, perceptions, and views (Candela, 2019; J. L. Johnson et al., 2020). Interviewee
transcript review is the primary method of verifying the credibility of a study since, in qualitative
research, the participants are the best judge of their own experiences.
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Method 3: Artifact Analysis
The third method of data collection consists of statistically analyzing the residency match
results. As the director of graduate medical education, I have access to all medical residency
applications submitted to the teaching hospital and selected for interviews in family medicine,
internal medicine, or emergency medicine. I also have access to all fellowship applications
submitted to the pulmonary disease, geriatric medicine, infectious disease, sports medicine, or
additional medicine programs. I requested and obtained site permission to use my access as an
employee for the purposes of this research study. After Match Day, March 17, 2023, I had access
to statistics regarding which medical residency and fellowship applicants were offered a
residency or fellowship position. This data was utilized to investigate RQ3 to determine if there
is a difference in the percent of URiMs receiving a residency or fellowship offer based on
whether they interviewed in-person or virtually.
Data Collection Procedures
Data was collected with permission from the teaching hospital CMO/Designated
Institutional Official of the Graduate Medical Education Office. Data collection occurred after
Match Day, which is scheduled for March 17, 2023. After Match Day, data was available
regarding whether each residency or fellowship applicant was offered a residency or fellowship
position. Data was also available regarding whether each URiM medical resident participated in
an in-person or virtual interview. Data collection for this phase of the study was complete when
data regarding all URiM applicants in hospital-wide programs has been tallied. This data
included the number of URiM applicants who interviewed in person, the number of URiM
applicants who interviewed virtually, and the number of URiM applicants in each category who
were given residency or fellowship offers on Match Day.
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Data Analysis
After Match Day, March 17, 2022, I had access to whether each applicant was given a
residency or fellowship offer. I tallied the number of URiM medical residency and fellowship
applicants that were given residency or fellowship offers with respect to whether they
interviewed in-person or virtually using hospital-wide data. Percentages will then be calculated
to assess whether there is a difference in the percent of URiMs receiving a residency or
fellowship offer based on whether they interviewed in-person or virtually. Chi-square analysis
was utilized to determine if there are statistically significant differences between URiM
physicians who interviewed virtually or in-person.
Ethics
Research can present both benefits and risks to the participants. As such, it is essential
that the researcher ensured that the well-being of the participants is maintained throughout the
research duration (Connelly, 2016). Adhering to set ethical standards through the process ensures
the well-being of the subjects. These set standards were clearly outlined in the Belmont report
(National Commission for the Protection of Human Subjects of Biomedical and Behavioral
Research, 1979). They include respect for persons, beneficence, and justice. I adhered to these
three ethical standards throughout the entirety of the study. Respect for persons involves
recognizing the autonomy of the research participants. Respect for persons was demonstrated by
providing all participants with information about the research study, as this augmented their
informed consent. I also gave the participants informed consent forms with information about the
study, as well as ensure the voluntary participation of the participants. The principle of
beneficence is concerned with the risks and benefits of the research and the report states that the
participants who bare the greatest risk should directly benefit from the research (Arifin, 2018).
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Beneficence was ensured by informing all the participants of the risks and benefits involved in
the study. The principle of justice is concerned with ensuring that the procedures applied in the
study are fair and that all the participants have an equal chance to participate (Beauchamp,
2008). All the participants were provided with an equal opportunity to take part in the study and
an equal chance to participate in the microaggressions and implicit bias survey and provide their
views, perceptions, and attitudes in the semi-structured open-ended interview process.
Clearance from University of Southern California’s Institutional Review Board (IRB)
will be sought to ensure that the researcher has the necessary authorization to conduct the
research. The University of Southern California requires IRB approval for all research studies
involving human subjects under the FDA regulations. The IRB can approve, request
modifications, or disapprove research requests if they do not meet the required thresholds
(Osborne & Luoma, 2018). I ensured that all the requirements for approval are met before
requesting approval.
The participants were provided with an information sheet for exempt studies. The
information sheet provided information on the nature of the study and the researcher's plans to
maintain anonymity and confidentiality for the participants in the study. All the participants were
informed that if they felt uncomfortable with the research, they could terminate their
participation in the research study without penalty or fear of repercussions. The participants were
notified of the potential risks and benefits gained by participating in the study after completing
the study. According to J. Creswell and Poth (2018), researchers should inform participants of
the potential risks involved in the study and potential benefits arising after the research study's
completion. The study does reveal the universities in which the participants attend medical
school to preserve confidentiality, and each participant was referred to by a pseudonym in all
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files derived from the study. All participants were informed of the mechanisms employed by the
researcher to preserve their anonymity and protect their confidentiality.
All the data gathered during the collection process remained confidential until I assigned
pseudonyms. I responsibly stored all the data, which will be kept safely for three years until the
research study is published (Hurst et al., 2020). Records will be stored and maintained following
the state and federal statutes that govern research procedures. Once the study is published, the
records will be disposed of safely to ensure the confidentiality of the study.
Limitations and Delimitations
Limitations are the elements of a study's potential weaknesses and are beyond the control
of the researchers (Theofanidis & Fountouki, 2018). Delimitations are the limitations that a
researcher sets on the study and are boundaries or limits they have set. I set several delimitations
in this research study. First, the study was delimited to URiM medical residency and fellowship
applicants who applied to a specific teaching hospital, MMC, in the western United States.
Second, the selected URiM medical residency applicants applied to residency programs in family
medicine, internal medicine or emergency medicine, whereas the URiM fellowship applicants
applied to fellowships in pulmonary disease, geriatric medicine, infectious disease, sports
medicine or addition medicine. These delimitations were chosen because I am the director of
Graduate Medical Education of the teaching hospital in which the study will take place. In
particular, my office oversees the aforementioned residency and fellowship programs.
One limitation of the study was associated with the choice of utilized convenience
sampling to choose participants. Convenience sampling is commonly used in research in the
social sciences, but it is neither purposeful nor strategic (Etikan et al., 2016). Moreover,
convenience sampling is often not representative of the general population and therefore presents
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a limitation to the transferability of the study. That notwithstanding, the medical residency and
fellowship application at the teaching hospital in question was open to any medical resident or
fellowship applicant that meets the minimum criteria of the teaching hospital. As such, the
sample selected by the study may be indicative of the general population; this possibility was
assessed by comparing the actual applicant pool of the teaching hospital to that of the NRMP.
Another limitation of the study is the notion that the results of the study are derived from the
participants' experiences and perceptions. It was assumed by the researcher that the participants
were truthful in their responses to both the RMAS and the semi-structured interviews. This,
however, cannot be guaranteed. The researcher attempted to mitigate the possibility of untruthful
answers by ensuring that the participants were aware that their identities are protected and that
no one, except the researcher, would know the specifics of their responses. The researcher also
ensured that the participants knew that their responses would not in any way affect the outcome
of the medical residency or fellowship offer process.

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Chapter Four: Results or Findings
The aim of this study was to investigate URiM medical residency and fellowship
applicants’ experiences with microaggressions and implicit bias at MMC, a teaching hospital in
the western United States. Multiple sources of quantitative and qualitative data were collected.
Specifically, survey, interview and artifact data were collected to understand the experiences of
URiM applicants with microaggressions and implicit bias during their residency or fellowship
interviews. Data was collected in three phases. First, URiM medical residency and fellowship
applicants were invited to participate anonymously in the RMAS survey regarding their
experiences with microaggressions during their interviews. Survey respondents had the option to
participant in semi-structured interviews, the second phase of data collection. The third phase of
data collection occurred after Match Day, March 17, 2023. After this date, data was collected
from program administrators regarding whether applicants received fellowship or residency
offers.
Semi-structured interviews were analyzed using content analysis. Initial codes were
derived from themes presented in the study’s literature review, including types of
microaggressions. Some examples of initial codes were microassault, microinsult and
microinvalidation, the general classes of microaggressions. Initial codes were reexamined to
classify and group microaggressions into common themes, or more specific occurrences of
microaggressions. Secondary codes for the microassault initial code included ascription of
intelligence, second class citizen, or pathologizing cultural values. Themes presented in this
chapter meet two criteria. First, a theme needed to encompass at least three codes. Second, a
theme must have been mentioned by at least three of the ten participants. Discrepant cases,
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where a participant disagreed with a major theme elucidated by the other participants, were also
identified and are discussed in this chapter.
Participants
In the 2022-2023 NRMP application cycle, 48,156 actively applied to residency and
13,919 actively applied to fellowship programs in the United States (NRMP, n.d.). At MMC,
4,029 URiM physicians applied to the seven programs under examination in this study. Five
hundred sixty-one (561) URiM candidates were invited to interview for their respective
programs, with 496 individuals completing residency or fellowship interviews. URiM physicians
who accepted and participated in residency or fellowship interviews were the potential
participant pool for this study. See Table 3 for a description of the target population.
Survey Participants
Invitations to participate in this research study were extended by email to all URiM
residency or fellowship candidates in the aforementioned residency or fellowship programs.
Thirty-three participants completed the RMAS survey. A summary of the participants’
demographic information is shown in Figure 1 and Figure 2.

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Table 3

URiM Applicants to Residency and Fellowship Programs at MMC

Program

# of applicants

# invited to interview

# interviewed

Geriatric Medicine

15

8

8
Infectious Disease 27 21 11
Pulmonary Disease 70 34 33
Sports Medicine 74 26 21
Emergency Medicine 566 86 75
Internal Medicine 1707 228 228
Family Medicine 1229 158 120

Figure 1

Survey Participants’ Gender Identities

0
2
4
6
8
10
12
14
16
18
Male Female Undisclosed
Number of Participants
Participants' Gender Identities
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Figure 2

Survey Participants’ Ethnicities

Of the 33 participants completing the RMAS survey, 25 identified as Latinx, five
identified as African American and three identified as having multiple ethnicities. Fifteen of the
participants were male, 17 were female, and one participant did not disclose their gender. All
participants’ gender identity was the same as their biological gender assigned at birth. Notably,
only one participant completed their residency or fellowship interview in-person. This fact
prevented statistical comparison of in-person and virtual interviews. Thus, it was necessary to
address RQ2 using qualitative data from the participants’ experiences with their in-person and
virtual interviews.
Interview Participants
The RMAS survey included an option for participants to express interest in completing
semi-structured interviews. Ten of the 33 survey participant completed semi-structured
0
5
10
15
20
25
African American Latinx Multiple Ethnicities
Number of Participants
Participants' Gender Identities
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interviews conducted by an independent interviewer. The interview participants’ demographic
characteristics are described in Table 4. Participants were given a pseudonym by the independent
interviewer to protect the participants’ confidentiality and anonymity.
Of the ten interview participants, seven participants were Latinx, while the remaining
three participants identified as African American. Three of the participants were male and seven
were female. Four participants were aged 25-29, four participants were aged 30-34 and one
participant was 35-39 years old. The independent interviewer asked each participant how many
of their residency and fellowship interviews were completed in-person or virtually. Those
percentages are contained in Table 4. Only one participant (Claude) completed all of their
interviews using only one modality. The other participants completed some interviews virtually
and other interviews in-person, allowing for a qualitative comparison of their in-person and
virtual interview experiences.

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Table 4

Interview Participants’ Demographic Characteristics

Percentage of interviews

Participant

Race

Gender

Age range

In-person

Virtual

Claude

African American

Male

25-29

0%

100%
Elena Latinx Female 30-34 80% 20%
Julia Latinx Female 25-29 40% 60%
Stephanie African American Female 25-29 50% 50%
Henry Latinx Male 25-29 60% 40%
Laura Latinx Female 30-34 70% 30%
Aysha African American Female 35-39 30% 70%
Miles Latinx Male 30-34 50% 50%
Herlinda Latinx Female 30-34 90% 10%
Nancy Latinx Female 25-29 60% 40%

Overall Findings

The purpose of this study was to look at potential implicit prejudice and
microaggressions encountered by URiM physicians during medical residency interviews.
Microaggressions and structural racism are rooted in societal, historical, and cultural norms, and
they have an impact on racial group disparity (Togioka et al., 2022). Medicine, like any other
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industry or subject, requires procedures and regulations that address both unconscious and
conscious structural racism. The findings of this study confirmed these past findings, notably
80% of all participants reported encountering microaggressions during interview processes.
Specifically, both in-person and virtual interviews, it becomes evident that microaggressions are
distressingly prevalent during these processes. The following sections detail the specific
microaggressions experienced. This statistic is alarming and highlights the pressing need for
heightened awareness and actionable change within these interview settings.
RQ1: How, If at All, Do URiM Residency and Fellowship Applicants Experience Implicit
Bias and Microaggressions In the Interview Process?
In this section, the experiences of URiM residency and fellowship applicants with
implicit bias and microaggressions are presented. Data derived from the qualitative and
quantitative inquiries are integrated to answer this research question. Five themes, corresponding
to different types of microaggressions or implicit bias, were elucidated by qualitative analysis of
interviews: (a) Foreigner in own land, (b) colorblindness, (c) sexism, (d) ascription of
intelligence, and (e) myth of meritocracy. Themes were determined based on concepts that the
participants noted. A theme was identified if more than two participants noted it. Therefore,
some themes are more prominent and will be discussed in descending order. The qualitative
themes for this research question are summarized in Table 5.
The themes of foreigner in own land and sexualization were also interrogated by the
RMAS survey. The RMAS survey also included four additional microaggression themes: (a)
assumption of criminality, (b) low-achieving or undesirable culture, (c) environmental
microaggressions, and (d) invisibility. Each of these 10 themes is now discussed.

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Table 5

Participants Experiences of Microaggressions in their Residency Interviews

Theme

Participants

Excerpt

Foreigner in own Land
Claude, Julia,
Stephanie, Miles,
Herlinda

“My interviewer heard my accent and
immediately asked me where I was born”
(Claude).

Colorblindness
Claude, Julia,
Stephanie, Aysha
“A current resident participating in my
interview told me that the department is one
big cultural melting pot” (Aysha).

Sexism
Elena, Julia,
Stephanie, Aysha
“I had an interviewer tell me that the
community was a great place to raise a
family. She assumed that because I was
female, I wanted to have children” (Elena).

Ascription of Intelligence
Julia, Stephanie,
Aysha
“One of my interviewers saw that I was
Latina and declared that the hospital needed
more Spanish speaking doctors. I had to
politely tell him that I’m working on
learning Spanish, but I don’t speak it
fluently. They looked visibly disappointed”
(Julia).

Myth of Meritocracy
Elena, Laura,
Herlinda
“A current resident described the only
residents chosen to lead case presentations
are the most qualified ones” (Herlinda). “I
had an interviewer tell me that the
community was a great place to raise a
family.

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Theme 1: Foreigner in Own Land

This theme was one of the six factors interrogated by the RMAS survey, and was also
elucidated by five participants (Claude, Julia, Stephanie, Miles, Herlinda) in qualitative
interviews. The foreigner in own land, or alien in own land, is a microaggressions in which an
individual feels as if they do not belong because of their racial identity (M. T. Williams et al.,
2021). These experiences can be derived from individuals’ accents, appearances, and other racial
characteristics.
Survey Results
The foreigner in own land microaggression was one of the six factors included in the
RMAS survey. Three survey items were modified and included to understand whether the
participants experienced the foreigner in own land microaggression. The results for these survey
items are shown in Table 6. The RMAS survey was assessed on a five-point Likert scale, with a
value of one indicating a response of strongly disagree, a value of two indicating a response of
disagree, a value of three indicating a response of neutral, a value of four indicating a response of
agree, and a value of five indicating a response of strongly agree.
As shown in Table 6, the average score for the foreigner in own land microaggression is
1.98, which corresponds to an average score of disagree. Notably, between 40-50% of
respondents indicated that they disagreed with statements about being a foreigner in their own
land, as indicated by the frequency of the low score being between 39.4 and 48.5% (Table 6).
Only two or three participants responded that they strongly agreed with the statements, as
indicated by the frequency of the high score being between 3% and 9.1%. These data suggest
that, in general, participants in this sample did not experience the foreigner in own land
microaggression during their residency and fellowship interviews. To understand whether
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applicants had different experiences based on their ethnicities, average scores were determined
for Latinx, African Americans, and participants with multiple ethnicities. These results are
shown in Table 7.

Table 6

RMAS Survey Data for Foreigner in own Land Microaggression

Item

Average
score

Standard
deviation

Low score (1)
(Frequency)

High score (5)
(Frequency)

Because of my race, my
interviewers assumed that I am
a foreigner.

2.15

1.77

1 (39.4%)

5 (6.1%)
Because of my race, my
interviewers suggested that I
am not a true American.
1.73 0.91 1 (48.5%) 5 (3.0%)
My interviewers asked me
where I am from, suggesting
that I don't belong.
2.06 1.34 1 (48.5%) 5 (9.1%)
Subscale Score 1.98 1.34

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Participants from multiple ethnic backgrounds had the lowest average score (1.67  1.21) for this
type of microaggression. There was variation in ANOVA was performed to determine if the
observed differences between groups were statistically significant. The results of the ANOVA
test are shown in Table 8.

Table 7

Summary Statistics for Foreigner in own Land Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 2.03 1.26
African American 5 1.87 0.83
Multiple 3 1.67 1.21

Table 8

ANOVA Table for Foreigner in own Land Microaggression

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)

2

0.9442

0.4721

0.326

0.7226
Error (within groups) 96 139.0153 1.4481

Total 98 139.9596 1.4282

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ANOVA examining the variance between groups indicates that there is not a statistically
difference in the variation between groups. Thus, individuals from different ethnic backgrounds
do not experience the foreigner in own land microaggression in significantly different
frequencies. The hypotheses guiding this investigation were:
H
01
: There is no difference in perceived microaggressions between URiM residency and
fellowship applicants based on racial identity.
H
A1
: There are statistically higher perceived microaggressions for Multiracial URiM
residency and fellowship applicants compared to
In evaluating hypotheses H01 and HA1, there was not enough evidence to support rejecting the
null hypothesis in favor of the alternative hypothesis. Therefore, it was concluded that there is no
difference in perceived foreigner in own land microaggression between URiM residency and
fellowship applicants based on racial identity in this sample.
Interview Findings
Five participants (Claude, Julia, Stephanie, Miles, Herlinda) noted the presence of the
foreigner in own land microaggression. The perpetual foreigner microaggression occurs when
members of minority groups feel as if they are an outside to the White-dominant society of the
United States (M. T. Williams et al., 2021). Claude, Herlinda and Stephanie, who all spoke with
an accent, recounted that some of their interviewers asked them where they were born, indicating
their foreignness in the United States. Herlinda said, “My interviewer commented that my accent
was pretty and asked me where I was born and grew up. I got very uncomfortable. I didn’t know
how to say that I grew up in Los Angeles.” Herlinda further expanded on her background, saying
that her parents grew up in Central America, but she was born and raised in the United States.
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Stephanie, who spoke with a British accent, believed her interviewer was unsettled by the
discrepancy between her accent, her appearance and her United States citizenship. She said,
I’m the proverbial cultural melting pot. My mom is Mexican. My dad is British. I was
born in Idaho. I look like my mom and have my dad’s accent. After I introduced myself,
my interviewer paused and said, ‘wow, I wasn’t expecting that.’ I was so uncomfortable.
I didn’t know what to do.
Thus, according to some participant responses, interviewers interpreted their accents as being
foreign, even though the candidates were born and raised in the United States.
Julia and Miles also reported feeling like a foreigner in their own land. Unlike the other
participants, Julia and Miles did not speak with accents. Julia recounted that her interviewer
asked her about her family’s origins. Julia said, “My interviewer tried to make small talk, but did
it in all the wrong ways. Instead of asking me about my experiences in medical school, he asked
me if my family had immigrated to the United States yet.” Miles also had a similar experience,
saying “My interviewer asked me if I was the only one in my family living in the United States.”
The experiences of these participants indicates that the experience of racial microaggressions
based on their accents or appearance. All participants represented by this theme were asked
about their family origins, despite being born and educated in the United States. These actions on
the part of their interviewers made them feel like foreigners in their own land.
Summary
In qualitative interviews, five of 10 participants in this sample reported experiencing the
foreigner in own land racial microaggression. The participants recounted experiences about their
interviewers, who made assumptions about their family origins based on the participants’ accents
and appearances. The participants reported feeling uncomfortable being asked about their
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families and where they grew up, believing this information was not relevant to their experiences
as physicians. However, RMAS data for this microaggression indicates that this microaggression
was experienced with low frequency and there were no significant differences in the experience
of the foreigner in own land microaggression among participant ethnic groups in this study.
Theme 2: Colorblindness
Four participants, Claude, Julia, Stephanie, and Aysha, described experiencing the
colorblindness microaggression during some of their residency interviews. Colorblindness is a
type of racial microaggression that denies people their individuality and lived experiences
(Neville et al., 2013). In being colorblind, people deny the individuality of ethnic minorities.
Aysha’s interviewer described their department as “one big cultural melting pot,” a comment
intended to make Aysha feel more comfortable about the ethnic diversity or the department. At
one of her interviews, Stephanie recalled that one of her interviewers repeatedly remarked that
“everyone gets treated the same.” While race was not explicitly stated, Stephanie believed that
the interviewer’s intention was to instill the idea that race did not influence departmental
decisions. Claude had the same experience as Stephanie, as they both interviewed at the same
program with the same interviewer. Thus, colorblindness was experienced by some participants
at their residency and fellowship interviews.
Theme 3: Sexism, Sexualization, or Exoticization
This theme was one of the six factors interrogated by the RMAS survey, and was also
elucidated by four participants (Elena, Julia, Stephanie, and Aysha) in qualitative interviews.
Sexualization is a microaggression in which an individual is attributed sexual or exotic
characteristics based on their racial identity (M. T. Williams et al., 2021). In contrast, sexism
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occurs irrespective of racial identity and is based on a person’s gender (Warren et al., 2022). The
participants’ experiences with sexism and sexualization are next discussed.
Survey Results
The sexualization or exoticization microaggression was one of the six factors included in
the RMAS survey. Three survey items were modified and included to understand whether the
participants experienced the sexualization or exoticization microaggression. The results for these
survey items are shown in Table 9. The RMAS is scored on a five-point Likert scale, with a
value of one corresponding to a response of strongly disagree and a value of five corresponding
to a response of strongly agree. As shown in Table 9, the average score for the sexualization
microaggression is 1.27, which corresponds to an average score of close to strongly disagree.
For these RMAS statements, a low score indicated a low prevalence of sexualization, whereas a
high score indicated a high prevalence of sexualization. Notably, 75-80% of participants
recorded the lowest score possible, a value of one, corresponding to strongly disagree. This data
is shown in the low score column of Table 9. These data suggest that, in general, participants did
not experience the sexualization or exoticization microaggression during their residency and
fellowship interviews. To understand whether applicants had different experiences based on their
ethnicities, average scores were determined for Latinx, African Americans, and participants with
multiple ethnicities. These results are shown in Table 10.

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Table 9

RMAS Survey Data for Exoticization or Sexualization Microaggression

Item

Average
score

Standard
deviation

Low score (1)
(Frequency)

High score (5)
(Frequency)

My interviewers suggested that I
am exotic in a sexual way
because of my race.

1.19

0.48

1 (81.8%)

3 (3.0%)
My interviewers viewed me in an
overly sexual way because of my
race.
1.23 0.56 1 (81.8%) 3 (6.1%)
My interviewers held sexual
stereotypes about me because of
my racial background.
1.39 0.88 1 (75.8%) 5 (3.0%)
Subscale Score 1.27 0.64

Table 10

Summary Statistics for Exoticization or Sexualization Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 1.24 0.63
African American 5 1.6 0.83
Multiple Ethnicities 3 1.17 0.41

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The results from the RMAS survey indicate that African Americans had a higher average
score for this type of microaggression (1.6  0.83) than the other groups of participants.
Participants from multiple ethnic backgrounds had the lowest average score (1.16  0.41) for the
sexualization or exoticization microaggression. ANOVA was performed to determine if the
observed differences between groups were statistically significant. The results of the ANOVA
test are shown in Table 11.

Table 11

ANOVA Table for Exoticization or Sexualization Microaggression

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)

2

1.6999

0.85

1.9997

0.141
Error (within groups) 96 40.8052 0.4251

Total 98 42.5051 0.4337

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ANOVA examining the variance between groups indicates that there is not a statistically
difference in the variation between groups. Thus, in this sample, individuals from different ethnic
backgrounds do not experience the sexualization or exoticization microaggression in
significantly different frequencies. In evaluating hypotheses H01 and HA1, there was not enough
evidence to support rejecting the null hypothesis in favor of the alternative hypothesis.
Therefore, it was concluded that in this study, there was no difference in perceived sexualization
or exoticization microaggression between URiM residency and fellowship applicants based on
racial identity.
Interview Findings
In qualitative interviews, some of the participants reported incidences of sexism,
sexualization or exoticization. Sexism is different from sexualization or exoticization. Sexism
occurs when an individual is discriminatory based on someone’s gender (Lu et al., 2020).
Sexualization, or exoticization, is the phenomenon of sexualizing an individual based on their
racial background (Mukkamala & Suyemoto, 2018). Aysha reported an incidence of
sexualization during the qualitative interviews examining her experiences. She said, “I had a
faculty member flat out ask me when I was going to start having children. She described the
hospital’s maternity policy in detail. I felt like she viewed me as promiscuous.” Aysha reported
feeling like her interviewers viewed her in a sexual manner based on her appearance.
Elena, Julia, and Stephanie experienced sexist comments during their interviews. For
example, Elena described, “I had an interviewer tell me that the community was a great place to
raise a family. She assumed that because I was female, I wanted to have children.” Elena went on
to express that she did not believe an interviewer would not have made the same comment to a
male candidate. While this was not a racial microaggression, Elena did experience a
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microaggression that isolated her as a female. Julia reported a similar experience. One of her
interviewers also spoke about the elementary and middle schools in the area, citing the hospital’s
community as an optimal place to raise children. Like Elena, Julia believed that she would not
have experienced this form of sexism if she was not a woman. Julia said, “One of the men in the
virtual interview – his mouth actually dropped. This just speaks to the fact that a male
interviewee would not have received such a response.” Thus, some participants experienced
sexism during their residency and fellowship interviews.
Summary
In qualitative interviews, only one participant reported experiencing the exoticization or
sexualization racial microaggression. Other participants, however, did encounter a similar
phenomenon, namely sexism, during their interviews, where interviewers made assumptions
about the participants because they were female. Participants reporting sexism, sexualization and
exoticization reported feeling uncomfortable when they encountered these microaggressions.
However, sexualization and exoticization was an infrequently experienced microaggression. This
conclusion is supported by RMAS data for this microaggression, which indicates that
sexualization or exoticization was experienced with low frequency and there were no significant
differences in the experience of the sexualization or exoticization microaggression among
participant ethnic groups in this study.
Theme 4: Ascription of Intelligence

The ascription of intelligence microaggression was described by three participants (Julia,
Stephanie and Aysha) during qualitative interviews. This theme was not identified in the survey
data. All participants mentioning this theme were ascribed the ability to speak Spanish based on
their appearance. Julia said:
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One of my interviewers saw that I was Latina and declared that the hospital needed more
Spanish-speaking doctors. I had to politely tell him that I’m working on learning Spanish,
but I don’t speak it fluently. They looked visibly disappointed.
Julia’s interviewer believed that she spoke Spanish because of her Latina heritage, ascribing the
intelligence of language speaking. Stephanie had a similar experience. She said, “One of my
interviewers saw that I was Latina and started speaking Spanish to me. I was so insulted and
humiliated. I ranked the program last.” Stephanie’s experience with this racial microaggression
influenced her overall impression of the program. She ranked the program last because she felt
like it wouldn’t be an inclusive environment where she would be understood.
At one of Aysha’s in-person interviews, the physician allowing candidates to observe
clinical rounds placed Aysha into an all-Latinx minority group of candidates. The physician took
that group of candidates to observe patients who were all of Latinx origin and spoke Spanish.
Rounds were also conducted in Spanish. Asyha said, “I didn’t speak Spanish. I didn’t understand
what was being said. I don’t think I was able to put my best foot forward. I felt like I was just
staring blankly.” Thus, Aysha’s faculty guide assumed that she spoke Spanish based on her
appearance, ascribing an intelligence based solely on race. Aysha mentioned this diminished her
overall interview experience at that institution.
Theme 5: Myth of Meritocracy
The myth of meritocracy is a type of racial microaggression in which someone argues
that meritocracy, or upward social mobility, occurs through one’s merits, rather than social
position or other factors, including race (Garrison et al., 2021). Three participants (Elena, Laura
and Herlinda) described experiencing the myth of meritocracy during their residency or
fellowship interviews. For example, Herlinda said, “A current resident described the only
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residents chosen to lead case presentations are the most qualified ones.” Herlinda believed the
resident was referencing race and gender in their statement. She explained, “What he meant to
say is that faculty weren’t choosing residents to participate based on their skin color or gender.”
Laura experienced a similar microaggression. She described:
One of the White residents remarked several times that all residents had an equal chance
of success. I feel like those sorts of comments are unnecessary. Why wouldn’t all
residents have an equal chance of success? It made me feel like all residents didn’t have
an equal chance. If that’s the case, which residents? Was I one just because I’m Latinx?
Or because I’m female? If there’s equity, it’s not necessary to make statements about
equity.
Laura mentioned that believed statements regarding the myth of meritocracy carry an implication
that there are differences based on race. In promoting the myth of meritocracy, individuals
highlight the underlying structural inequities. Thus, some participants experienced the myth of
meritocracy microaggression during their residency and fellowship interviews.
Theme 6: Assumption of Criminality
The assumption of criminality microaggression was one of the six factors included in the
RMAS survey. As noted in the introduction of themes, the following themes were only identified
using RMAS survey data and not through qualitative data. This microaggression occurs when
individuals assume that someone has criminal behavior based on their racial background (Sue &
Spanierman, 2020). Three survey items were modified and included to understand whether the
participants experienced the assumption of criminality microaggression. The results for these
survey items are shown in Table 12. Survey questions were assessed on a five-point Likert scale,
98

with a value of one indicating a response of strongly disagree and a value of five indicating a
response of strongly agree.
As shown in Table 12, the average score for the assumption of criminality
microaggression is 1.83, which corresponds to an average score of close to disagree. As with the
other racial microaggressions, most participants in this study (50-60%) strongly disagreed with
the statements. This is evidenced in the low score frequency column of Table 12.

Table 12

RMAS Survey Data for Assumption of Criminality Microaggression

Item

Average
score

Standard
deviation

Low score (1)
(Frequency)

High score (5)
(Frequency)

My interviewers made assumptions about
my intelligence and abilities because of
my race.

1.85

1.15

1 (54.5%)

5 (3.0%)
My interviewers treated me with distrust
because of my race.
1.67 1.11 1 (60.6%) 5 (3.0%)
I felt singled out by my interviewers
because of my race.
1.97 1.28 1 (51.5%) 5 (6.1%)
Subscale Score 1.83 1.18

99

Table 13

Summary Statistics for Assumption of Criminality Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 1.68 1.09
African American 5 2.73 1.34
Multiple Ethnicities 3 1.33 0.52

These data suggest that, in general, participants did not experience the assumption of criminality
microaggression during their residency and fellowship interviews. To understand whether
applicants had different experiences based on their ethnicities, average scores were determined
for Latinx, African Americans, and participants with multiple ethnicities. These results are
shown in Table 13.
The results from the RMAS survey indicate that African Americans in this study reported
a higher average score for this type of microaggression (2.73  1.33) than the other groups of
participants. Participants from multiple ethnic backgrounds had the lowest average score (1.33 
0.52) for the assumption of criminality microaggression. ANOVA was performed to determine if
the observed differences between groups were statistically significant. The results of the
ANOVA test are shown in Table 14.

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Table 14

ANOVA Table for Assumption of Criminality Microaggression

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)
2 15.4734 7.7367 6.3343 0.0026**
Error (within groups) 96 117.2538 1.2214

Total 98 132.7273 1.3544

Note: *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001

ANOVA analysis indicates that in this study, there was a statistically significant
difference between the three groups of participants (F = 6.33, df = 98, p = 0.0026). In evaluating
hypotheses H01 and HA1, for the assumption of criminality microaggression, there is enough
evidence to support rejecting the null hypothesis that participants from all racial backgrounds
experienced the same frequency of microaggressions. This leads to the conclusion that in the
study’s sample, there is a significant difference in perceived assumption of criminality
microaggressions between URiM residency and fellowship applicants based on racial identity.
ANOVA analysis has limitations in that it does not elucidate what differences between
the group are, just that there is a statistically significant difference (Buckless & Ravenscroft,
1990). Therefore, to understand which racial demographics experience the assumption of
criminality microaggression more than others, a post-hoc Tukey test was performed to examine
significant differences between pairs of participant groups. Post-hoc tests allow for the
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exploration of differences between multiple group means while controlling the experiment-wise
error rate (Barnett et al., 2022). The results of the post-hoc Tukey Test for the assumption of
criminality microaggression are shown in Table 15.

Table 15

Post-Hoc Tukey Test for Assumption of Criminality Microaggression

Pair

Difference

SE

Q

Lower
CI

Upper
CI

Critical
mean

p-value

Latinx –
African Americans

1.0538

0.2203

4.7832

0.3121

1.7956

0.7418

0.0030**
Latinx – Multiple 0.3462 0.3311 1.0455 0.7685 1.4608 1.1146 0.7408
African Americans –
Multiple
1.4 0.3775 3.7087 0.1291 2.6709 1.2709 0.0272*

Note: *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001

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Analysis of the post-hoc Tukey test indicates that there two comparisons produced
statistically significant differences. African American residency applicants experienced
significantly higher assumption of criminality microaggressions than Latinx candidates (p =
0.003) and participants with multiple ethnicities (p = 0.0272). Notably, there was no significant
difference between Latinx candidates and candidates with multiple ethnic heritages in this
sample. These findings indicate that in this sample, African Americans experience the
assumption of criminality microaggression at a significantly higher frequency than Latinx
participants or those with multiple ethnicities.
Theme 7: Low Achieving or Undesirable Culture Microaggression
The low achieving or undesirable culture microaggression was one of the six factors
included in the RMAS survey. This microaggression occurs when someone believes that an
individual from an ethnic minority is low achieving solely based on their racial background (Sue
& Spanierman, 2020).

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Table 16

RMAS Survey Data for Low Achieving or Undesirable Culture Microaggression

Item

Average
score

Standard
deviation

Low score
(Frequency)

High score
(Frequency)

My interviewers acted as if they can
fully understand my racial identity, even
though they are not of my racial
background.
2.52 1.46 1 (39.4%) 5 (9.1%)
My interviewers acted as if all of the
people of my race are alike
2.29 1.27 1 (39.4%) 5 (3.0%)
My interviewers suggested that people
of my racial background get unfair
benefits, such as those associated with
affirmative action.
1.87 1.28 1 (57.6%) 5 (6.0%)
My interviewers assumed that people of
my racial background would succeed in
life if they simply worked harder.
1.71 0.96 1 (54.5%) 4 (6.1%)
My interviewers denied that people of
my race face extra obstacles when
compared to Whites.
1.87 1.20 1 (54.5%) 5 (3.0%)
My interviewers assumed that I am
successful because of affirmative action,
not because I earned my
accomplishments.
1.77 1.18 1 (60.6%) 5 (3.0%)
My interviewers hinted that I should
work hard to prove that I am not like
other people of my race.
1.56 0.85 1 (60.6%) 4 (3.0%)
My interviewers suggested that my
racial heritage is dysfunctional or
undesirable.
1.58 0.89 1 (60.6%) 4 (6.1%)
My interviewers focused only on the
negative aspects of my racial
background.
1.65 1.41 1 (63.6%) 5 (6.1%)
Subscale Score 1.87 0.21
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Nine survey items were modified and included to understand whether the participants
experienced the low achieving or undesirable culture microaggression. The results for these
survey items are shown in Table 16. The RMAS survey questions were assessed on a five-point
Likert scale, with a value of one indicating a response of strongly disagree and a value of five
indicating a response of strongly agree. As shown in Table 16, the average score for the low
achieving or undesirable culture microaggression is 1.87, which corresponds to an average score
of close to disagree. At least 39.4% of participants in this study responded that they strongly
disagreed with each of the statements for this RMAS factor. This is evidenced by the low score
frequency column of Table 16. These data suggest that, in general, participants did not
experience the low achieving or undesirable culture microaggression during their residency and
fellowship interviews.
To understand whether applicants had different experiences based on their ethnicities,
average scores were determined for Latinx, African Americans, and participants with multiple
ethnicities. These results are shown in Table 17.

Table 17

Summary Statistics for Low Achieving or Undesirable Culture Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 1.83 1.18
African American 5 2.07 1.14
Multiple Ethnicities 3 1.56 0.78

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Table 18

ANOVA Table for Low Achieving or Undesirable Culture Microaggression

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)

2

3.737

1.8685

1.4023

0.2477
Error (within groups) 294 391.7446 1.3325

Total 296 395.4816 1.3361

The results from the RMAS survey indicate that African Americans in this study reported
a higher average score for this type of microaggression (2.07  1.14) than the other groups of
participants. Participants from multiple ethnic backgrounds had the lowest average score (1.56 
0.78) for the low achieving or undesirable culture microaggression. ANOVA was performed to
determine if the observed differences between groups were statistically significant. The results of
the ANOVA test are shown in Table 18.
ANOVA examining the variance between groups indicates that in this study, there is not
a statistically difference in the variation between groups. Thus, individuals from different ethnic
backgrounds in this sample do not experience the low achieving or undesirable culture
microaggression in significantly different frequencies. In evaluating hypotheses H01 and HA1,
there was not enough evidence to support rejecting the null hypothesis in favor of the alternative
hypothesis. Therefore, it was concluded that in this sample, there is no difference in perceived
low achieving or undesirable culture microaggression between URiM residency and fellowship
applicants based on racial identity.
106

Theme 8: Environmental Microaggressions
Environmental microaggression was one of the six factors included in the RMAS survey.
This microaggression occurs when there are systematic inequities in an organization that makes
one group feel invalidated (Sue & Spanierman, 2020). Five survey items were modified and
included to understand whether the participants experienced environmental microaggressions.
The results for these survey items are shown in Table 19. The RMAS survey was assessed on a
five-point Likert scale, with a value of one indicating a response of strongly disagree and a value
of five indicating a response of strongly agree.
As shown in Table 19, the average score for the environmental microaggression is 3.16,
which corresponds to an average score of close to neutral. This type of microaggression had the
highest score of the six factors.

107

Table 19

RMAS Survey Data for Environmental Microaggressions

Item

Average
score

Standard
deviation

Low score
(Frequency)

High score
(Frequency)

My interviewers assumed that I am
knowledgeable about multicultural
issues, simply because I am a member
of a racial minority group.

3.03

1.38

1 (24.2%)

5 (18.2%)
My interviewers asked me to serve as a
spokesperson for people in my racial
group.
2.00 1.41 1 (54.5%) 5 (12.1%)
When I interacted with my
interviewers, they were of a different
racial background.
3.94 1.26 1 (9.1%) 5 (42.4%)
I noticed that there are few faculty and
residents/fellows of my racial
background that were represented in
my interview.
3.65 1.31 1 (3.0%) 5 (36.4%)
I was the only person of my racial
background in the interview setting.
3.19 1.52 1 (18.2%) 5 (27.3%)
Subscale Score 3.16 1.38

These data suggest that, in general, participants in this study experienced environmental
microaggression during their residency and fellowship interviews. This is evidenced by a larger
frequency of participants choosing the high score on the RMAS, corresponding to a value of
strongly agree (Table 19). To understand whether applicants had different experiences based on
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their ethnicities, average scores were determined for Latinx, African Americans, and participants
with multiple ethnicities. These results are shown in Table 20.
The results from the RMAS survey indicate that African Americans and Latinx in this
study had roughly the same average scores for environmental microaggressions. Participants
from multiple ethnic backgrounds had the lowest average score (2.60  1.17) for environmental
microaggressions. ANOVA was performed to determine if the observed differences between
groups were statistically significant. The results of the ANOVA test are shown in Table 22.
ANOVA examining the variance between groups indicates that in this sample, there is not a
statistically difference in the variation between groups. Thus, individuals from different ethnic
backgrounds do not experience environmental microaggressions in significantly different
frequencies. In evaluating hypotheses H01 and HA1, there was not enough evidence to support
rejecting the null hypothesis in favor of the alternative hypothesis. Therefore, it was concluded
that in this sample, there is no difference in perceived environmental microaggressions between
URiM residency and fellowship applicants based on racial identity.

Table 20

Summary Statistics for Environmental Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 3.19 1.56
African American 5 3.20 1.47
Multiple Ethnicities 3 2.60 1.17

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Table 21

ANOVA Table for Environmental Microaggressions

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)
2 3.2429 1.6214 0.695 0.5006
Error (within groups) 162 377.969 2.3331

Total 164 381.2119 2.3245

Theme 9: Invisibility
The invisibility microaggression was the final factors included in the RMAS survey. This
microaggression occurs when someone believes they are ignored or overlooked based on their
racial identity (Sue & Spanierman, 2020). Seven survey items were modified and included to
understand whether the participants experienced the invisibility microaggression. The results for
these survey items are shown in Table 22. The RMAS survey was assessed on a five-point Likert
scale, with a value of one indicating a response of strongly disagree and a value of five indicating
a response of strongly agree.
As shown in Table 22, the average score for the invisibility microaggression is 3.16,
which corresponds to an average score of close to neutral. This type of microaggression also had
the highest score of the six factors, achieving the same score as environmental microaggressions.
While a low frequency of participants scored these RMAS statements high (see Table 22), there
was a significant proportion of participants who scored neutral or agree. These data suggest that,
in general, participants experienced invisibility microaggression during their residency and
110

fellowship interviews. To understand whether applicants had different experiences based on their
ethnicities, average scores were determined for Latinx, African Americans, and participants with
multiple ethnicities. These results are shown in Table 23.

Table 22

RMAS Survey Data for Invisibility Microaggressions

Item

Average
score

Standard
deviation

Low score
(Frequency)

High score
(Frequency)

I was treated like a second-class
citizen because of my race.

1.65

1.11

1 (63.6%)

5 (3.0%)
I received poorer treatment during my
interview because of my race.
1.74 1.03 1 (58.6%) 4 (9.1%)
My interviewers of other racial
groups expected me to behave in a
way that is not consistent with my
own racial or cultural values
1.84 1.07 1 (48.5%) 5 (3.0%)
Sometimes I felt as if my interviewer
looked past me or didn’t see me as a
real person because of my race.
1.97 1.33 1 (57.6%) 5 (3.0%)
I felt invisible because of my race. 1.90 1.22 1 (57.6%) 5 (3.0%)
I felt ignored because of my race. 1.87 1.28 1 (60.6%) 5 (3.0%)
My contributions are dismissed or
devalued because of my racial
background.
1.81 0.98 1 (51.5%) 5 (3.0%)
Subscale Score 3.16 1.38

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Table 23

Summary Statistics for Invisibility Microaggression

Participant ethnicity

n

Average

Standard deviation

Latinx 25 1.71 1.13
African American 5 2.40 1.04
Multiple Ethnicities 3 1.29 0.61

Table 24

ANOVA Table for Invisibility Microaggressions

Source

df

Sum of square

Mean square

F Statistic

p-value

Groups (between groups)

2

17.783

8.8915

7.4856

0.0007***
Error (within groups) 228 270.823 1.1878

Total 230 288.606 1.2548

Note: *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001

112

The results from the RMAS survey indicate that African Americans in this study had a
higher average score (2.40  1.04) for the invisibility microaggression than participants from the
other ethnic groups. Participants in this study from multiple ethnic backgrounds had the lowest
average score (1.29  0.61) for the invisibility microaggression. ANOVA was performed to
determine if the observed differences between groups were statistically significant. The results of
the ANOVA test are shown in Table 24.

Table 25

Post-Hoc Tukey Test for Invisibility Microaggression

Pair

Difference

SE

Q

Lower
CI

Upper
CI

Critical
mean

p-value

Latinx –
African Americans
0.6912 0.1422 4.8595 0.2167 1.1658 0.4746 0.0020**
Latinx –
Multiple Ethnicities
0.4231 0.2137 1.9794 -0.29 1.1362 0.7131 0.3428
African Americans –
Multiple Ethnicities
1.1143 0.2437 4.5723 0.3012 1.9274 0.8131 0.0040**

Note: *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001

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ANOVA analysis indicates there was a statistically significant difference between the
three groups of participants (F = 7.4856, df = 230, p = 0.0007). In evaluating hypotheses H01 and
HA1, for the invisibility microaggression, there is enough evidence to support rejecting the null
hypothesis that in this sample, participants from all racial backgrounds experienced the same
frequency of microaggressions. This leads to the conclusion that in this sample, there is a
significant difference in perceived invisibility microaggressions between URiM residency and
fellowship applicants based on racial identity. To understand which racial demographics
experience the invisibility microaggression more than others, a post-hoc Tukey test was
performed to examine significant differences between pairs of participant groups. The results of
the post-hoc Tukey Test for the invisibility microaggression are shown in Table 25.
Analysis of the post-hoc Tukey test indicates that there were two comparisons that
produced significant contributions to the variance observed in the ANOVA test. African
American residency applicants in this study experienced significantly higher invisibility
microaggressions than Latinx candidates (p = 0.002) and participants with multiple ethnicities (p
= 0.004). Notably, there was no significant difference between Latinx candidates and candidates
with multiple ethnic heritages in this study. These findings indicate that in this sample, African
Americans in this study experienced the invisibility microaggression at a significantly higher
frequency than Latinx participants or those with multiple ethnicities.
RQ2: Differences in URiM Residency and Fellowship Applicants’ Experiences Based on
Interview Modality
In this section, the experiences of URiM residency and fellowship applicants with implicit
bias and microaggressions are compared based on whether they interviewed in-person or
virtually. Originally, I intended to analyze both qualitative and quantitative data for this research
114

question. However, only one participant completing the RMAS survey completed an in-person
interview at MMC. This fact made statistical analysis comparing in-person and virtual interviews
impossible. Therefore, data derived from qualitative analysis of interviews was used to answer
this research question. Participants’ experiences with implicit bias and microaggressions during
their virtual interviews elucidated one theme: forced diversity. On the other hand, data analysis
for participants completing in-person interviews revealed one additional theme: only minority
candidate. Microaggressions were common to both interview modalities, specifically
participants noted the two following microaggressions: environmental microaggressions and
denial of individual racism.
Participants’ Experiences with Virtual Interviews
Each participant, except for Claude, participated in both in-person and virtual interviews
during the interview period. See Table 4. Asking questions about both types of experiences
allowed me to understand the differences in microaggressions that occurred based on interview
modality.
Theme 1: Forced Diversity
The first theme identified by the participants regarding virtual interviews was forced
diversity. Forced diversity was mentioned by four participants: Julia, Aysha, Miles and Herlinda.
Aysha described, “At my virtual interview, the only candidates present in the interview group
were minorities. There were no White candidates. It felt like the program was disingenuous
about the level of diversity in the program.” Aysha was placed into an interview group that only
contained minority candidates, which she believed was a programmatic decision to make the
minority candidates feel comfortable about the diversity of the program. However, this decision
had the opposite effect, as the participants experiencing this forced diversity were more unsettled
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than comforted. For instance, Julia said, “I was uncomfortable not having White candidates in
the interview group. I didn’t think that reflected well on the program. It’s not realistic to think
that there were no White resident applicants.” Like Aysha, Julia believed that the lack of White
candidates in their interview group was disingenuous and did not accurately reflect the diversity
of the program. This made the participants uncomfortable during their residency or fellowship
interviews.
Other participants also experienced forced diversity on their interviews. For example,
Herlinda said, “It was very strange being in a group with only minority candidates. The whole
situation was even more uncomfortable with all interviewers being White.” Herlinda describes a
situation consistent with systematic racism. All minority candidates being placed in one group is
akin to segregation. Placing all minority candidates with White interviewers also reinforces one
of the central tenets of critical race theory, namely the White individuals are in positions of
power (Delgado & Stefancic, 2017). Thus, this example of implicit bias is consistent with many
of the principles on which critical race theory was founded.
Theme 2: Environmental Microaggressions
Two participants identified environmental microaggressions as being a component of
their virtual interviews. Three participants (Elena, Stephanie and Herlinda) also described
environmental microaggressions in the context of their in-person interviews. Claude and Aysha
encountered environmental microaggressions in their virtual interviews. For example, Claude
said, “The only current residents who came to the virtual events at the interview were White. It
made me question the diversity of the program.” This is an example of an environmental
microaggression because the lack of representation at events suggests a lack of diversity in the
program. In this case, Claude felt invalidated by the fact that no residents from with minority
116

backgrounds attended the virtual events. Aysha also experienced environmental
microaggressions during her virtual interview. She said:
When I went to my virtual interviews, the only faculty and residents present were White.
I had researched the program prior to attending the interview. I knew the program had
about 15% minority residents. Not having them at the interview made me feel strange
about being a minority at the interview functions.
Both Aysha and Claude described situations where current URiM residents and faculty were
noticeably absent from the virtual events. This could constitute examples of environmental
racism. On the one hand, if there were not URiM residents and faculty in the program, this would
indicate a lack of diversity at the programmatic level. On the other hand, if URiM residents and
faculty did not prioritize attending the interview events, this may suggest to applicants that the
current URiM physicians are not happy with the program.
Elena, Julia, and Herlinda also reported environmental microaggressions, but during their
in-person interviews. For example, Herlinda said, “When we were touring the hospital, the guide
made a point of only letting us see White patients with relatively minor illnesses. They visibly
skipped ethnic minorities’ rooms” (P9). Herlinda’s experience was similar to the participants
who reported not having other URiM physicians and residents present at the interview events. In
this case, the program guides made conscious decisions to prevent the candidates from observing
patients who were minorities. Julia had an experience that was the opposite of Herlinda. In one
of Julia’s in-person interviews, they grouped URiM physicians together and only allowed them
to observe ethnic minority patients. Thus, environmental microaggressions were present in
participants’ virtual and in-person residency and fellowship interviews.
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Theme 3: Denial of Individual Racism
Three participants also experienced organizational denial of individual racism in both
their virtual and in-person interviews. Claude, Aysha, and Miles all experienced denial of
institutional racism in their virtual interviews. In this form of microaggression, individuals deny
the presence of racism at individual or structural levels. For example, Miles said, “When I asked
about the culture of the program, my interviewer responded, ‘culture, race and gender has no
influence on an individual’s success in this residency program.’” Miles interpreted this comment
to mean that he was asking about the program’s culture because of his racial or gender identity.
In reality, resident happiness is critical to the success of the medical residency training period
(Salles et al., 2014). Thus, the interviewer denied individual racism by denying that culture
influenced residents’ success. Aysha also experienced this form of microaggression. She said:
I’m really passionate about doing outreach into the local community. At my medical
school, I did thousands of volunteer hours in the local clinic working with
underprivileged community members. I asked about similar opportunities at the residency
program. My interviewer said, ‘Our clinic sees patients from all walks of life in the
community, not just underprivileged ones.’ I felt like she diminished my question, in
addition to not answering it.
Aysha’s interviewer denied individual racism by diverting attention from the underprivileged
community members to focus on other demographic groups, including those who are affluent.
Notably, the interviewers in these cases denied individual racism, but did so on a programmatic
level because they were making statements regarding the culture and diversity of the residency
and fellowship programs.
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Aysha and Herlinda also described denial of individual racism during their in-person
interviews. For example, Herlinda said, “My in-person interviewers were more emotionally
charged about their program being culturally diverse. They made it a point to let candidates
know that they didn’t make decisions based on culture, race or sex.” Herlinda had a similar
experience in her in-person interviews to Aysha’s experience during her virtual interviews. The
interviewer reminded candidates that decisions were not made based on culture, race or gender.
However, some participants, including Aysha, interpreted this statement to mean that some
decisions were based on those factors. Thus, in denying individual racism, the interviewer
affirmed the presence of structural racism to some degree in the program. Thus, based on
participant responses, denial of individual racism was experienced during both in-person and
virtual interviews.
Participants’ Experiences with In-Person Interviews
As described above, participants reported themes common to virtual and in-person
interviews: environmental microaggressions and denial of individual racism. One additional
theme was elucidated in analysis of the qualitative data for participants’ descriptions of their in-
person interviews. This one additional theme is: only candidate from a minoritized background.
Theme 4: Only Candidate from a Minoritized Background
Three participants (Julia, Aysha and Miles) describe themselves as being the only
minority candidate at one of their in-person interviews. Julia described, “I was the only minority
candidate at one of my in-person interviews. All of the faculty who came to the interview were
White. It was unnerving. I ranked that program very low.” This finding is in opposition to some
of the experiences reported by other participants. For example, in Theme 1 of this research
question, some participants reported forced diversity at their virtual interviews in which they
119

were grouped with only minority candidates. Julia, Aysha and Miles had the opposing
experience at one of their in-person interviews, being the only minority applicant. Miles reported
feeling uneasy about being the only minority applicant. He said:
I felt like I stuck out like a sore thumb. I was the only minority present at the didactic
day. In all of my years of education, I’ve never been the only minority in a class or
program. It made me very uneasy. I wasn’t sure if my being the only minority applicant
spoke to the diversity of the program, or if it was just a coincidence. If it was a
coincidence, there’s no way to assess that because you can’t just ask that question of
organizers.
Miles, Aysha, and Julia experienced implicit bias in a different way. Being the only minority
applicant raised questions about the programs’ commitment to diversity, inclusion, and equity.
Moreover, the lack of diversity in the interview environment led the participants to question
whether they would be a good fit for the program.
RQ3: Difference in Residency or Fellowship Offers Based on Interview Modality
I originally intended to compare the proportions of URiM physicians offered residency or
fellowship positions based on whether they interviewed in-person or virtually. However, during
the 2022-2023 interview cycle, all programs at MMC conducted virtual interviews, except for
Emergency Medicine. Therefore, this line of inquiry was not possible. To answer this research
question, I compared the proportions of URiM physicians who were offered residency or
fellowship positions in the 2019 and 2020 cycles, which contained only in-person interviews,
and the 2021, 2022 and 2023 cycles, which contained only virtual interviews. The raw data for
this analysis is shown in Table 26. Analysis of Table 26 shows the distribution of URiM
physicians interviewed and matched in each of the programs at MMC from 2018-2023. URiM
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residency and fellowship applicants completed in-person interviews during the 2019 and 2020
cycles and virtual interviews during the 2021-2023 cycles. The total number of matched URiM
physicians who interviewed in-person and virtually is shown in Table 27. Data from the Geriatric
and Infectious Disease programs are omitted from this analysis due to having an incomplete data
set for comparison. A chi-squared test for independence was performed to determine if there was
a significant difference between the two distributions. The chi-squared statistic was χ
2
= 2.07,
with four degrees of freedom. This corresponded to a p value of 0.7223, which indicates that in
this study, there was not a significant difference between the distributions of URiM physicians
matched based on interview modality. That is, individuals did not have a statistically significant
difference in being selected matched based on whether the candidate interviewed in-person or
virtually.

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Table 26

URiM Physicians Interviewed and Matched in MMC Programs 2019-2023

In-person interviews

Virtual interviews

2019

2020

2021

2022

2023

I

M

I M

I

M

I

M

I

M

Geriatric

NA

NA

NA

NA

NA

NA

7

0

7

0
Infectious NA NA NA NA 7 0 10 0 8 0
Pulmonary NA NA 19 0 24 2 30 0 27 1
Sports 8 1 11 0 20 1 20 0 14 0
Emergency 57 1 20 1 82 1 8 0 57 2
Family 18 1 103 2 39 3 38 3 42 2
Internal 24 4 32 1 47 3 24 2 35 5

Note: I = Interviewed, M = Matched

Table 27

Number of Matched URiM Physicians Interviewing Virtually or In-Person

Program

In-person interviews

Virtual interviews

Pulmonary

0

3
Sports 1 1
Emergency 2 3
Family 3 8
Internal 5 9

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Summary of Results and Findings
In Research Question 1, I investigated the experiences of URiM medical residency and
fellowship applicants with racial microaggressions during their residency interviews. Eighty
percent of interviewed participants reported experienced at least one form of racial
microaggression during their medical residency interview. Five main types of racial
microaggressions were identified by participants in qualitative interviews, including the
foreigner in own land, sexism or sexualization/exoticization, colorblindness, ascription of
intelligence, and myth of meritocracy. The participants experiencing these microaggressions felt
they invalidated because of their ethnic heritage. Notably, participants experiencing
colorblindness and the myth of meritocracy believed that statements about the colorblindness or
equity of a program did not need to be stated if they were truly equitable or diverse. Other
participants reported feeling uncomfortable talking about their ethnic backgrounds because they
did not expect questions about their backgrounds to be a prominent feature of their residency
interviews.
The RMAS survey also addressed RQ1 by examining the participants’ experiences with
foreigner in own land, assumption of criminality, low achieving, or undesirable culture,
environmental and invisibility microaggressions. Of these microaggressions, foreigner in own
land, assumption of criminality and low achieving or undesirable culture were not commonly
experienced by the participants. However, the participants denoted higher levels of
environmental and invisibility microaggressions. The experience of assumption of criminality
and invisibility microaggressions was significantly higher for African American participants than
Latinx candidates or participants with multiple ethnic backgrounds. The experience of the other
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types of microaggressions included on the RMAS survey did not differ significantly among
participant groups.
In Research Question 2, I examined whether participants had different experiences with
racial microaggressions and implicit bias during their in-person and virtual interviews. Data for
this research question came qualitative investigation into the participants’ experiences. Notably,
the participants had roughly equal reports of racial microaggressions during their in-person and
virtual interviews. The most common types of microaggressions the participants experienced,
irrespective of interview modality, were environmental microaggression and denial of individual
racism. Moreover, the interviewers who denied individual racism did so in a manner that denied
racism on the part of the program, which made the participants question the programs’
commitment to diversity and inclusion. More research is needed to fully understand whether in-
person or virtual interviews provide URiM residency applicants with a better experience.
In Research Question 3, I investigated whether there was a significant difference in the
number of URiM physicians who matched with MMC programs based on interview modality.
The results of this inquiry indicate there is not a significant difference between the number of
URiM physicians who matched with MMC programs based on whether they interviewed in-
person or virtually. Chapter 5 will present evidence-based recommendations to address the
identified results or findings, ensuring that actionable steps are proposed to address the issues
and promote positive change in the relevant areas.

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Chapter Five: Discussion and Recommendations
The purpose of this mixed methodological study was to explore URiM medical resident
and fellowship applicants’ experiences with racial microaggressions during their residency and
fellowship interviews. Experiences were compared based on the participants’ ethnic
backgrounds, as well as whether they participated in in-person or virtual interviews. Chapter
Five begins with a presentation of the study’s findings and results. These findings will be placed
within the context of the existing academic literature, as discussed in the literature review. Next,
the chapter contains evidence-based recommendations based on the study’s findings. Limitations
and delimitations of the study are also discussed. Finally, the chapter concludes with
recommendations for future research and the broader implications of the study.
Discussion of Findings
This mixed methodological study examined the experiences of URiM medical residency
and fellowship applicants with racial microaggressions during their residency interviews.
Notably 80% of all participants reported encountering microaggressions during interview
processes. Specifically, both in-person and virtual interviews, it becomes evident that
microaggressions are distressingly prevalent during these processes. RMAS survey results
indicate that in the study’s sample, African American participants experienced the highest degree
of some types of microaggressions compared to participants from other ethnic backgrounds.
These microaggressions included assumption of criminality and invisibility microaggressions.
These results are congruent with some findings present in the literature. For example, Appah-
Sampong et al. (2022) used the RMAS survey to investigate microaggressions among surgeons,
findings that African Americans surgeons had the highest scores on the invisibility scale
compared to surgeons from other ethnic groups. However, Appah-Sampong et al. (2022) also
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found that Latinx surgeons scored significantly higher on the foreigner in own land scale
compared to other surgeons. In this study, there was no significant difference between foreigner
in own land scores for African Americans, Latinx, or residents from multiple ethnic
backgrounds. These findings suggest that microaggressions and implicit bias may differ
depending on the stage of an individual’s medical career. Congruent with this interpretation, in a
study by Bullock et al. (2020), 82% of Black medical students reported experiencing stereotypes,
implicit bias and microaggressions, compared to 43% of Latinx medical students.
The findings from the qualitative interviews of participants' experiences highlight
concerning instances of environmental racism and microaggressions during residency and
fellowship interviews. Specifically, four participants witnessed an ascription of intellect
microaggression in which they were presumed to speak Spanish based on their appearance. This
type of microaggression reinforces stereotypes and diminishes individuality. Moreover, all four
participants reported experiencing colorblindness microaggressions, which disregards the racial
or ethnic identities of individuals and denies their unique experiences (Neville et al., 2013).
These findings are congruent with the findings of Cruz et al. (2019) who used the psychometric
Microaggressions in Health Care Scale to evaluate perceived racial microaggressions and
discrimination in over 250 African American and Latinx respondents and found that minorities
face multiple forms of discrimination in the medical field. These findings highlight the
significance of instituting cultural sensitivity and competency training to address and prevent
these microaggressions, thereby fostering an interview environment that is more inclusive and
respectful.
During the qualitative interviews, two participants noticed a dearth of URiM residents
and faculty at virtual events, indicating a lack of diversity at the programmatic level. The
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participants described that this absence may signal to applicants that the program does not
prioritize or value URiM representation, which could discourage aspiring physicians from
underrepresented groups. Interestingly, Blanchard et al. (2022) explained that medical students
had higher levels of satisfaction when provided opportunities to interact with minority medical
educators. Additionally, the findings are congruent with Page et al. (2011), who reported that
lack of diversity among faculty in academic medical institutions can be detrimental to minority
medical students. Furthermore, another participant’s account of being joined with URiM
physicians and permitted to observe only ethnic minority patients during an in-person interview
is indicative of environmental microaggressions. Such actions can propagate stereotypes and
marginalize candidates for URiM, thereby reinforcing systemic biases within the healthcare
system. These instances of ambient racism and microaggressions highlight the significance of
fostering inclusive and equitable interview environments in which URiM candidates are afforded
the same opportunities and experiences as their peers.
The analysis of the qualitative interviews also revealed one theme unique to virtual
interviews: forced diversity. Delgado and Stefancic (2017) explained that forced diversity
suggests that virtual interviews may establish an environment where diversity is emphasized,
thereby decreasing the incidence of explicit bias and discriminatory conduct. In contrast, the
analysis of in-person interviews revealed two additional themes: environmental
microaggressions and denial of individual racism. Many studies discussed the financial benefits
of virtual interviews (Awe & Ai, 2022; Fuchs & Youmans, 2020; Rajendran & Nadler, 2022),
however, the equity and microaggressions still seem equally as present. Nevertheless, it is
noteworthy that two microaggressions, environmental microaggressions and denial of individual
racism, were common to both interview formats, highlighting the pervasive nature of
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discriminatory behavior regardless of the interview format. However, Moran et al. (2021)
explained that most applicants and medical program directors thought that virtual interviews
enhanced the equity of applicants. These findings indicate a need to further research the equity in
virtual and in-person interviews.
Recommendations for Practice
Although the U.S. population is increasingly diverse, healthcare overall has been
relatively slow to diversify within the workforce (AMSNY, 2020). Institutional and structural
discrimination is embedded in healthcare institutions and affects marginalized populations. This
study demonstrates that URiM medical residency and fellowship applicants experienced racial
microaggressions during their in-person and virtual residency interviews. There are three
recommendations identified below to address key findings.
Recommendation 1: Increase Cultural Sensitivity and Competency Training
Eighty percent of interviewed participants reported experienced at least one form of racial
microaggression during their medical residency interview. The prevalence of racial
microaggressions during medical residency interviews must be addressed based on the findings
and results that surfaced from the data analysis. One effective strategy is to increase cultural
sensitivity and competency training for all interviewing healthcare professionals (Brottman et al.,
2020). By providing comprehensive training on cultural sensitivity, bias recognition, and
effective communication skills, medical institutions can equip their staff with the skills necessary
to navigate delicate conversations and interactions with individuals from diverse backgrounds
(Brottman et al., 2020; S. Young & Guo, 2020).
Training in cultural sensitivity and competence can play a pivotal role in nurturing an
inclusive and respectful interview environment for all candidates. According to S. Young and
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Guo (2020) and Brottman et al. (2020), training sessions can educate healthcare professionals on
the nuances of racial microaggressions, enabling them to recognize and avoid perpetuating these
behaviors. In addition, Overland et al. (2019) reported that training can improve the ability of
healthcare professionals to interact with candidates from diverse racial and ethnic backgrounds,
ensuring that interviews are conducted with respect and cultural sensitivity. Ultimately, this
recommendation seeks to create a more inclusive and equitable environment in which candidates
are evaluated on the basis of their qualifications and merit, as opposed to being subjected to
discriminatory experiences.
Recommendation 2: Increase URiM Faculty Participation in Residency Interviews
Some participants reported instances of being the only minority candidate, while others
described their interviews as lacking URiM faculty and current resident participation. To address
the participants' concerns regarding the dearth of diversity and representation during residency
interviews, it is essential to prioritize the inclusion of URiM faculty and current residents in the
interview process. Increasing the participation of URiM faculty and residents can help create an
environment that is more welcoming and inclusive of candidates from diverse backgrounds
(Gutierrez-Wu et al., 2022).
When URiM candidates observe faculty members and residents with similar racial or
ethnic backgrounds, it can cultivate a sense of belonging and instill confidence in the institution's
dedication to diversity and inclusion. For aspiring healthcare professionals from
underrepresented communities, URiM faculty and residents can provide distinct perspectives,
mentorship, and serve as role models by providing a unique perspective, offering mentorship,
and serving as role models (Chung & Armitage-Chan, 2022). Their participation in the interview
process can also help mitigate instances of bias and provide a more accurate evaluation of the
129

qualifications and prospective fit of candidates within the program. Furthermore, Ford and
Airhihenbuwa (2010) and Mahmud and Gagnon (2020) posited that medical institutions can
demonstrate their commitment to cultivating a diverse workforce and promote a more equitable
selection process by actively recruiting and involving URiM faculty and residents in residency
interviews.
Recommendation 3: Offer Applicants Options for Virtual or In-Person Interviews
On the basis of participant feedback, medical institutions must provide applicants with
the option to choose between virtual and in-person interviews. By offering both virtual and in-
person interview options, candidates can select the format that best suits their comfort level,
preferences, and requirements (Kraft et al., 2022). In-person interviews may offer benefits in
terms of fostering a more intimate and direct connection between candidates and interviewers,
which may reduce instances of microaggressions and implicit bias (Maurer, 2021; Pourmand et
al., 2018). Nonetheless, it is crucial to ensure that in-person interviews adhere to diversity and
inclusion guidelines and that all candidates are treated equitably. Nevertheless, virtual interviews
can be a convenient and accessible option for candidates who encounter logistical obstacles or
who prefer the convenience of their own homes (Maurer, 2021). By providing applicants with a
selection of interview formats, medical institutions can accommodate a variety of circumstances
and foster an inclusive interview process that respects each candidate's unique experiences and
requirements (Bernstein et al., 2020).
Integrated Recommendations
This proposed program aims to integrate the recommendations of increasing cultural
sensitivity and competency training, increasing URiM faculty participation in residency
interviews, and offering applicants options for virtual or in-person interviews. By implementing
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these recommendations, the program seeks to foster an inclusive and equitable environment
during the residency interview process. The guiding framework for this study, CRT, emphasizes
the need to recognize systemic prejudice and to combat and eliminate it (Solorzano, 1998). By
increasing cultural sensitivity and competency training, organizations can combat biases,
cultivate understanding, and promote equitable residency interview practices. Increasing URiM
faculty participation in interviews also ensures representation, combats discriminatory evaluation
criteria, and promotes diversity and inclusion. Additionally, offering applicants the choice
between virtual and in-person interviews is consistent with CRT principles by recognizing
individual circumstances, accommodating diverse needs, and fostering equal opportunities for all
applicants regardless of their backgrounds or circumstances (Solorzano, 1998; Solorzano &
Yosso, 2001). The following program proposal was developed by using findings from Brottman
et al. (2020) and Lanting et al. (2019):
The following proposal outlines a sequence for implementing the recommendations and
provides a timeline for their execution.
Step 1: Needs Assessment and Program Development
Based on recommendations 1 and 2, a comprehensive needs assessment should be
conducted. To this end, MMC should use surveys, interviews, and focus groups to collect
information from faculty, residents, and applicants about their experiences and areas of concern
regarding cultural sensitivity, competency, and diversity during the interview process. The
collected data should be analyzed to identify specific areas for improvement and to inform the
development of the training curriculum and strategies to increase participation among URiM
faculty.
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Based on recommendation 1, MMC should develop a comprehensive training curriculum.
It is important to collaborate with diversity and inclusion specialists, cultural competency
educators, and medical education experts to develop a curriculum that addresses cultural
awareness, implicit bias, effective communication skills, and inclusive interview practices.
Program officials should incorporate interactive seminars, case studies, and role-playing
exercises to enhance participants' knowledge and abilities in navigating diversity-related issues
during interviews.
Step 2: Training Implementation and Faculty Recruitment
Based on recommendation 1, MMC should implement mandatory cultural sensitivity and
competency training. This training program should be implemented for all faculty members,
residents and interviewers who participate in the residency and fellowship interview process.
Seminars and training sessions should be planned throughout the year, ensuring wide
participation and accessibility.
Based on recommendation 2, strategies for increasing URiM faculty participation should
be developed. MMC should collaborate with professional organizations, diverse medical
societies, and academic institutions to identify and attract URiM physicians interested in
academic careers. It is also important to establish mentorship and support programs to promote
the growth and development of URiM faculty within the institution. It is also essential to engage
URiM faculty members in the interview process. To this end, MMC should encourage URiM
faculty to participate as interviewers and panelists during residency interviews. Guidelines and
training must be provided to ensure equitable and unbiased assessment of candidates by URiM
faculty.

132

Step 3: Virtual and In-Person Interview Implementation
Based on Recommendation 3, MMC should offer residency and fellowship applicant’s
options for virtual or in-person interviews. Program directors should communicate clearly to
applicants the choice between virtual and in-person interviews, emphasizing the benefits and
considerations of each mode. Program directors should also provide comprehensive guidance on
preparing for and optimizing the interview experience in both formats. Standardized evaluation
criteria and rubrics should be implemented. Program directors should develop evaluation criteria
and scoring rubrics that are consistent across virtual and in-person interviews. Interviewers
should be trained to assess candidates based on their qualifications, skills, and fit within the
program, regardless of the interview format.
Proposed Timeline for Integrated Recommendations
A proposed timeline for these integrated recommendations is as follows. During Months
1-2 of the new DEI program implementation, the program director should conduct and analyze
the needs assessment. A curriculum should be developed based on evidence from this analysis.
During Months 3-8, cultural sensitivity and competency training should be implemented. During
this time frame, URiM faculty recruitment should proceed to secure their involvement in the
interview process. During Months 9-12, virtual and in-person interview options should be
implemented for interview candidates, including standardized evaluation criteria and rubrics.
Limitations and Delimitations
Delimitations are the limitations that a researcher sets on the study and are boundaries or
limits they have set. I set several delimitations in this research study. First, the study was
delimited to URiM medical residency and fellowship applicants who applied to MMC, a specific
teaching hospital in the western United States. Second, the selected URiM medical residency
133

applicants applied to residency programs in family medicine, internal medicine or emergency
medicine, and the URiM fellowship applicants applied to fellowships in pulmonary disease,
geriatric medicine, infectious disease, sports medicine or addition medicine. These delimitations
were chosen because I am the director of Graduate Medical Education at MMC. In particular, my
office oversaw the aforementioned residency and fellowship programs.
Limitations are the elements of a study's potential weaknesses and are beyond the control
of the researchers (Theofanidis & Fountouki, 2018). One limitation of the study was associated
with the choice of utilized convenience sampling to choose participants. Convenience sampling
is commonly used in research in the social sciences, but it is neither purposeful nor strategic
(Etikan et al., 2016). Moreover, convenience sampling is often not representative of the general
population and therefore presents a limitation to the transferability of the study. Notwithstanding,
the medical residency and fellowship application at the teaching hospital in question is open to
any medical resident or fellowship applicant that meets the minimum criteria of the teaching
hospital. As such, the sample selected by the study may be indicative of the general population;
this possibility will be assessed by comparing the actual applicant pool of the teaching hospital to
that of the NRMP. It is assumed by the researcher that the participants were truthful in their
responses to both the RMAS and the semi-structured interviews. This, however, cannot be
guaranteed. The researcher will attempt to mitigate the possibility of untruthful answers by
ensuring that the participants are aware that their identities are protected and that no one, except
the researcher, will know the specifics of their responses. The researcher will also ensure that the
participants know that their responses will not in any way affect the outcome of the medical
residency or fellowship offer process.
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Recommendations for Future Research
Future research recommendations should include studies on microaggressions and bias in
both virtual and in-person medical residency and fellowship interviews. Due to the increasing
prevalence of virtual interviews, it is essential to investigate how microaggressions and biases
manifest in this format and whether they differ from traditional in-person interviews. Research
should investigate the effect of nuanced discriminatory behaviors, such as microinvalidations and
implicit bias, on the experiences and outcomes of URiM applicants. Additionally, it would be
beneficial to investigate potential strategies to mitigate and resolve these biases, such as
standardized interview protocols or training for interviewers on implicit bias. Future research can
contribute to the creation of more fair and inclusive selection processes in graduate medical
education by concentrating on microaggressions and bias in both virtual and in-person
interviews.
It would be beneficial to expand the scope of future research beyond a solitary teaching
facility in the western United States. The external validity of the study's findings would be
enhanced if it included multiple institutions from distinct regions, each with a unique set of
experiences and circumstances. This would provide a deeper comprehension of the difficulties
and opportunities encountered by URiM medical residency and fellowship applicants across the
country.
Implications for Equity
The findings of this study and subsequent recommendations to increase cultural
sensitivity and competency training, increase URiM faculty participation in residency interviews,
and offer applicant’s options for virtual or in-person interviews all have substantial equity
implications. By increasing cultural sensitivity and competency training, organizations can foster
135

a greater appreciation for diverse cultural histories, backgrounds, and experiences. Similarly,
increasing URiM faculty participation in residency interviews contributes to equity by providing
representation and diverse perspectives that challenge systemic biases and promote selection
process fairness. Lastly, providing applicants with the option to participate in virtual or in-person
interviews acknowledges and accommodates their unique circumstances. The purpose of these
recommendations is to promote equity by increasing awareness, representation, and accessibility
during the residency interview.
Conclusion
The aim of this study was to investigate URiM medical residency and fellowship
applicants’ experiences with microaggressions and implicit bias. As residency programs gain
more experience and collect more data about their in-person and virtual interview experiences, it
is important to examine URiM physicians' experiences with in-person and virtual interviews to
determine if there are pattern differences that may disadvantage URiM applicants. Participants'
experiences were contrasted based on their ethnicity and whether they participated in in-person
or virtual interviews. Chapter Five discussed the findings of the study and outlined
recommendations supported by evidence based on the study's findings. Specifically, based on the
finding that 80% of participants experienced a form microaggression, recommendations included
increase cultural sensitivity and competency training, increase URiM faculty participation in
residency interviews and offer applicants options for virtual or in-person interviews.
Three instruments were used to assess participants’ experiences in this study. First, the
RMAS survey was used to assess the prevalence of different types of racial microaggressions.
Specifically, the RMAS survey examined the participants’ experiences with foreigner in own
land, assumption of criminality, low achieving or undesirable culture, environmental and
136

invisibility microaggressions. Of these microaggressions, foreigner in own land, assumption of
criminality and low achieving or undesirable culture were not commonly experienced by the
participants. However, the participants denoted higher levels of environmental and invisibility
microaggressions. The experience of assumption of criminality and invisibility microaggressions
was significantly higher for African American participants than Latinx candidates or participants
with multiple ethnic backgrounds. The experience of the other types of microaggressions
included on the RMAS survey did not differ significantly among participant groups.
The second instrument used in this study was qualitative interviews investigated the
experiences of URiM medical residency and fellowship applicants with racial microaggressions
during their residency interviews. Five main types of racial microaggressions were identified by
participants in qualitative interviews, including the foreigner in own land, colorblindness, sexism
or sexualization/exoticization, ascription of intelligence, and myth of meritocracy. The
participants experiencing these microaggressions felt they invalidated because of their ethnic
heritage. Notably, participants experiencing colorblindness and the myth of meritocracy believed
that statements about the colorblindness or equity of a program did not need to be stated if they
were truly equitable or diverse. Other participants reported feeling uncomfortable talking about
their ethnic backgrounds because they did not expect questions about their backgrounds to be a
prominent feature of their residency interviews.
In the qualitative interviews, I also examined whether participants had different
experiences with racial microaggressions and implicit bias during their in-person and virtual
interviews. The participants reported roughly equal reports of racial microaggressions during
their in-person and virtual interviews. The most common types of microaggressions the
participants experienced, irrespective of interview modality, were environmental
137

microaggression and denial of individual racism. Moreover, the interviewers who denied
individual racism did so in a manner that denied racism on the part of the program, which made
the participants question the programs’ commitment to diversity and inclusion. In this study,
some participants viewed their in-person interviews as being more equitable than their virtual
interview, while other participants had the opposite opinion. Finally, I performed artifact analysis
comparing match results from 2019-2020, which only used in-person interviews, and 2021-2023,
which only used virtual interviews. Results from this analysis demonstrated at URiM residency
and fellowship applicants had equal chances of matching with their respective programs based
on interview modality.
This study has implications for DEI programs and initiatives at teaching hospitals and
other medical education institutions. The study’s results and findings indicate that some medical
residency and fellowship applicant experienced microaggressions during their residency and
fellowship interviews. Employee and interviewer training may be key in mitigating the harmful
effects of racial microaggressions and implicit bias. By increasing cultural sensitivity and
competency training, organizations can foster a greater appreciation for diverse cultural histories,
backgrounds, and experiences by educating hospital faculty about the prevalence and types of
microaggressions in academic medicine. Similarly, increasing URiM faculty participation in
residency interviews contributes to equity by providing representation and diverse perspectives
that challenge systemic biases and promote selection process fairness. Such actions may allow
for greater equity in academic medicine, allowing teaching hospitals and residency programs to
attract top URiM candidates to their institutions.

138

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Appendix A: RMAS Survey
This research survey is part of a dissertation study. It is designed to better understand the
prevalence of microaggressions experiences among underrepresented minorities in medicine
(URiM) and the effects that these occurrences have during the residency interview process. The
goal with this research is to help promote change where needed, and to make all graduate
medical education programs more inclusive.

For this study you will be asked a few demographic questions, followed by statements to reflect
back on during your residency interview. The study should take about 5-7 minutes to complete.
Your participation in this research is voluntary. If you have any questions about this study please
contact, CM Manlandro at dr.cm@procge.org, a third-party independent contractor acting on
behalf of the Principal Investigator of this study, Sandra Gonzales, for confidentiality purposes.

Please think of your experience in the residency/fellowship interview at MMC.
I need to collect some demographic information to aid in my dissertation analysis:
1. Did you participate in a virtual or in-person interview with this medical residency
program? (Virtual Interview, In-Person Interview)
2. What is your biological gender? (Male, Female, Prefer not to Disclose)
3. What is your gender identity? (Male, Female, Trans Male/Trans Man,
Trans Female/Trans Woman, Genderqueer/Gender Nonconforming, Different Identity,
Prefer not to Disclose)
4. Are you a minority? (Yes, No, Prefer not to Disclose)
5. What is your ethnicity? (American Indian or Alaskan Native
Asian / Pacific Islander, Black or African American, Hispanic/Latinx, White/Caucasian
Multiple ethnicity/ Other (please specify)
Indicate your agreement to the following statements as you reflect back on your residency
interview: Interviewers include one or more faculty and current residents/fellows and these
experiences pertain to both formal and informal interactions. (1-Strongly Disagree, 2-Disagree,
3-Neutral, 4-Agree, 5- Strongly Agree)

1. Because of my race, my interviewers assumed that I am a foreigner.
2. Because of my race, my interviewers suggested that I am not a “true” American.
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3. My interviewers asked me where I am from, suggesting that I don’t belong.
4. My interviewers made assumptions about my intelligence and abilities because of my
race.
5. My interviewers treated me with distrust because of my race.
6. I felt singled out by my interviewers because of my race.
7. My interviewers suggested that I am “exotic” in a sexual way because of my race.
8. My interviewers viewed me in an overly sexual way because of my race.
9. My interviewers held sexual stereotypes about me because of my racial background.
10. My interviewers acted as if they can fully understand my racial identity, even though they
are not of my racial background.
11. My interviewers acted as if all of the people of my race are alike.
12. My interviewers assumed that I am knowledgeable about multicultural issues, simply
because I am a member of a racial minority group.
13. My interviewers asked me to serve as a “spokesperson” for people in my racial group.
14. My interviewers suggested that people of my racial background get unfair benefits, such
as those associated with affirmative action.
15. My interviewers assumed that people of my racial background would succeed in life if
they simply worked harder.
16. My interviewers denied that people of my race face extra obstacles when compared to
Whites.
17. My interviewers assumed that I am successful because of affirmative action, not because
I earned my accomplishments.
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18. My interviewers of other racial groups expected me to behave in a way that is not
consistent with my own racial or cultural values.
19. My interviewers hinted that I should work hard to prove that I am not like other people of
my race.
20. My interviewers suggested that my racial heritage is dysfunctional or undesirable.
21. My interviewers focused only on the negative aspects of my racial background.
22. I was treated like a second-class citizen because of my race.
23. I received poorer treatment during my interview because of my race.
24. When I interacted with my interviewers, they were of a different racial background.
25. I noticed that there are few faculty and residents of my racial background that were
represented in my interview.
26. I was the only person of my racial background in the interview setting.
27. Sometimes I felt as if my interviewer looked past me or didn’t see me as a real person
because of my race.
28. I felt invisible because of my race.
29. I felt ignored because of my race.
30. My contributions are dismissed or devalued because of my racial background.
Are you interested in participating in an interview regarding your medical residency
interview? Your responses to this survey will remain anonymous. Please note that not all
who volunteer to participate in the survey will be selected. If you are selected to participate
in an interview, the researcher will contact you to schedule a Zoom meeting. (Yes, No).
(Participants who select yes will be provided a link to a separate survey to provide their
contact information.)

The researcher is raffling three Amazon gift certificates in denominations of $100, $50, and
$25. Would you like to enter for a chance to win an Amazon gift card? Your responses will
remain anonymous. (Yes, No). (Participants who select yes will be provided a link to a
raffle administered by Qualtrics.)

172

Appendix B: Interview Protocol
Interviewer Script: Hello, NAME. My name is Dr. Cara Marie Manlandro and I’m an
independent interviewer for Sandra Gonzales, a doctoral student at Rossier School of Education
at the University of Southern California. This study is part of her efforts to obtain a Doctor of
Education. She appreciates you taking the time to share your experiences with me. The purpose
of this study is to examine the experiences of URiMs who participate in-person versus virtual
interviews in order to determine whether there are patterned differences that may provide a
disadvantage for residency URiM applicants from URiM backgrounds. This dissertation aims to
ultimately distinguish how in-person versus virtual interviews may impact the recruitment and
selection process of URiMs and make recommendations to improve strategies in increasing
diversity within graduate medical education. You play a crucial role in this study by sharing your
insights. Thank you for providing your consent to participate. As a reminder, you are not
required to participate in this study and we can stop the interview at any time. I will be recording
this interview. Your name and organization will not be associated with your responses and will
be kept confidential. Do you have any questions before we begin? Okay, great let’s get started.
Interview Questions:
1. Please tell me about your residency and fellowship application experience. (RQ1, RQ2)
2. What was your interview experience like? (RQ1, RQ2: CRT - Residency Access)
a. Where did your interview take place? (CRT - Residency Access)
b. What was the best part of your interview experience? (Screening/Background)
c. What about your interview experience could have been improved? (RQ1, RQ2:
CRT - Residency Access)
3. Describe your experience relating to how your questions were answered during your
interview. (RQ1, RQ2: CRT Oppression)
173

4. Describe your connection with your interviewers. (RQ1, RQ2: CRT-Residency Access)
a. In what ways did you connect with them? (RQ1, RQ2: CRT-All)
b. What could have made your connection stronger? (RQ1, RQ2: CRT-All)
5. In what ways were you able to demonstrate your strength as a residency candidate?
(RQ1, RQ2: CRT Access, HC System)
6. What opportunities did the interview provide for you to learn more about the culture of
the residency program? (RQ1, RQ2: CRT-All)
7. How do you feel your interview experience positioned you as a candidate? (RQ1, RQ2:
CRT- Residency Access)
8. Please describe any experiences of bias and microaggressions, if any, that occurred
during your interview. (RQ1, RQ2: CRT-All)
9. How, if at all, you experience implicit bias and/or microaggressions in the interview
process? (RQ1, RQ2: CRT- All)
10. What else would you like to share based on your interview experience?
Interviewer Script: That is all of the questions that I have for you. I’d like to thank you again for
your time and for sharing your experience with me. Stop recording, close the interview.

174

Appendix C: Recruitment Flyer

175

Appendix D: Information Sheet for Exempt Studies
University of Southern California
Rossier School of Education
Waite Phillips Hall, 3470 Trousdale Pkwy, Los Angeles, CA 90089

INFORMATION SHEET FOR EXEMPT RESEARCH
STUDY TITLE: The Evaluation of In-Person versus Virtual Interviews from Underrepresented
Minorities in Medicine
PRINCIPAL INVESTIGATOR: Sandra Gonzales, MS Edu.
INDEPENDENT CONTRACTOR: Cara Marie Manlandro
FACULTY ADVISOR: Helena Seli, PhD

You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.

PURPOSE
The purpose of this study is to examine the experiences of Black and Latinx individuals who
participated in in-person or virtual interviews in order to determine whether there are patterned
differences that may provide a disadvantage for residency and fellowship Black and Latinx
applicants from URiM backgrounds and make recommendations or practice to increase
equity/reduce bias. We hope to learn how in-person versus virtual interviews may impact the
recruitment and selection process of Black and Latinx applicants and make recommendations to
improve strategies for increasing diversity within graduate medical education. You are invited as
a possible participant because you are a physician from racial and ethnic groups that are
described as underrepresented in medicine and have direct knowledge of the experiences under
study. Because the primary investigator (PI), Sandra Gonzales, is an employee of this institution,
a private contractor will conduct the data collection and your information will remain
anonymous to the PI.

PARTICIPANT INVOLVEMENT
If you decide to take part in the survey, you will be asked to:
 Take the anonymous Racial Microaggressions Scale survey (5-7 minutes)
 At the end of the survey, you will have the option to enter a raffle to win one of three
Amazon Gift Cards ($100, $50, or $25)

If, in addition, you decide to take part in the interview, you will be asked to:
 Select a time for participating in a Zoom interview (5 minutes) with an independent
contractor
 Participate in a Zoom interview (45-60 minutes) with an independent contractor
176

 With your permission, the interview will be recorded. You can decline to be recorded and
will be able to continue to participate.
 A $25 Amazon Gift Card will be provided to all volunteers that complete an interview

CONFIDENTIALITY
The members of the research team and the University of Southern California Institutional
Review Board (IRB) may access the data. The IRB reviews and monitors research studies to
protect the rights and welfare of research subjects.

When the results of the research are published or discussed at conferences, no identifiable
information will be used. The study will not reveal the universities in which the participants
attend medical school to preserve anonymity, and each participant will be referred to by a
pseudonym in all files derived from the study.

The data collected for this study via the survey will be anonymous. The data will be stored in a
password-protected computer and will be destroyed after 3 years.
An independent, private contractor will conduct audio-recorded one-to-one interviews using
Zoom to ensure the confidentiality of the participants. The private contractor will conduct the
interviews, transcribe the recordings, remove all identifiers, and assign pseudonyms for all
participants before delivering the dataset to the PI. The names of the participants and the audio
recordings will be withheld from the PI to ensure that the PI remains neutral and cannot identify
any of the participants. All potential identifying information will be redacted from transcription
as well as field notes. You have the right to review the interview transcript and make any edits
you deem necessary.

INVESTIGATOR CONTACT INFORMATION
If you have questions about this study, please contact Cara Marie Manlandro, Independent
Contractor at (301) 956-0886 or email dr.cm@procge.org.

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.

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Asset Metadata

Creator Gonzales, Sandra (author)

Core Title The evaluation of in-person versus virtual interviews from underrepresented minorities in medicine

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-08

Publication Date 08/15/2023

Defense Date 07/26/2023

Publisher University of Southern California. Libraries (digital)

Tag diversity,equity,fellowship applicants,implicit bias,in-person interviews,medical healthcare workforce.,medical residency,minority physicians,OAI-PMH Harvest,racial microaggressions,residency applicants,residency interviews,Teaching Hospital,underrepresented physicians,virtual interviews

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Phillips, Jennifer L. (committee member), Cisneros, Victor (committee member)

Creator Email sandrag0@usc.edu,sandragee28@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113298171

Unique identifier UC113298171

Identifier etd-GonzalesSa-12255.pdf (filename)

Document Type Dissertation

Rights Gonzales, Sandra

Internet Media Type application/pdf

Type texts

Source 20230816-usctheses-batch-1085 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA

Repository Email cisadmin@lib.usc.edu