Implementing a “Distance Traveled” Question to Improve Resident Diversity: Process and Feasibility

Abstract

Increasing diversity in the physician workforce is important to improving racial and ethnic disparities in health outcomes in the United States. We describe the implementation of a “distance traveled” question (DTQ) in our residency application process. For the 2021-2022 cycle, all applicants to the University of Washington otolaryngology residency program were allowed to complete an optional DTQ. Responses were shared with the application review committee. Following the distribution of interview invites, an anonymous survey was sent to all faculty reviewers. The response rate was 26 of 36 (72%). Among respondents, 20 (77%) felt that the DTQ helped them learn something new about the applicant, and 19 (73%) reported that the DTQ influenced their decision making about the applicant. Thus, a DTQ may provide faculty with new and influential information regarding residency applicants.

Increasing physician workforce diversity is important in addressing racial and ethnic disparities in US health outcomes. ¹ Holistic review of applicants’ quantitative academic metrics and qualitative experiences ² improves diversity along the medical education continuum.^3-6 The Association of American Medical Colleges provides a broad framework for holistic review. ² However, there are few granular descriptions of the implementation process at the graduate medical education (GME) level. ⁷ We share our department’s experience implementing holistic review in the otolaryngology residency application process by developing a “distance traveled” question (DTQ).

Distance traveled is the metaphorical distance that an applicant travels throughout life and a composite measure of achievement ⁸ ( Figure 1 ). This distance varies by the cumulative adversities faced in terms of social identities, income, wealth, occupation, education, social capital, community, culture, and other factors. These adversities are thought to lend insight into desirable traits, such as empathy, interpersonal skills, emotional resilience, capacity for growth, cultural sensitivity, commitment to service, and strength of character. ⁹

Figure 1.

The metaphorical “distance” that an applicant travels varies by obstacles encountered. These depend on the socioeco- nomic milieu into which the applicant was born and what they experienced during development.

Materials and Methods

This project was exempt from formal review by the University of Washington (UW) Institutional Review Board.

We designed a DTQ based on discussions with the Kaiser Permanente family medicine program in Seattle and the University of Michigan’s Department of Otolaryngology–Head and Neck Surgery regarding their DTQ implementation. We obtained approval from the UW GME office and the UW School of Medicine legal team to deploy the DTQ, which is presented in Figure 2 .

Figure 2.

“Distance traveled” question in web form presented to applicants.

All 2021-2022 applicants to the UW otolaryngology–head and neck surgery residency program were offered to complete the optional DTQ in addition to their Electronic Residency Application Service (ERAS) application. Responses were provided to the application review committee. After interview invitations were sent, all faculty who reviewed applications were anonymously surveyed ( Figure 3 ) to discern whether the DTQ provided new and/or influential information not found elsewhere in the application.

Figure 3.

RedCap survey sent to faculty on the application review committee.

Results

We received 498 applications, and 218 (44%) had responses to the optional DTQ. We interviewed 50 applicants, 12 (24%) of whom responded to the optional DTQ. Thirty-six faculty interviewed applicants, among whom 26 (72%) responded to the anonymous survey. Of these, 20 (77%) reported that the DTQ helped them learn something new about the applicant, and 19 (73%) indicated that the DTQ influenced their decision making about the applicant. Several faculty noted that some responses provided information that was already presented elsewhere in the application. Others expressed that the DTQ was helpful and that the next step should be to implement a metric to quantitatively assist with ranking.

Discussion

Our faculty felt that the DTQ provided additional information to the ERAS application, which affected decisions on extending interview invitations and final rank order.

During the process, we overcame challenges that may be informative to other programs seeking to implement similar processes. The DTQ arose from our department’s diversity committee and after multiple iterations was presented to our GME and legal personnel, who helped guide further development. The UW legal team counseled us on state and federal legislation, including Washington State Initiative 200, Federal Executive Order 11375, the Rehabilitation Act of 1973, and Title VII of the Civil Rights Act of 1964. We were advised to keep the DTQ generic and broad, allowing applicants to describe their own experience in an open response, rather than asking about discrete aspects of their identity or eliciting yes/no responses about specific forms of discrimination. Consulting with the legal team provided legitimacy to an initiative not yet used in other departments at UW.

Adding a DTQ did not have unanimous support in the department. Many of our faculty provided thoughtful responses when discussing the use of the DTQ. Some expressed doubt that the DTQ would reduce bias in a meaningful way. Some faculty emphasized that while “grit” is a good quality, it does not necessarily indicate alignment with our department’s historical focus on recruiting applicants interested in academic medicine and research. Some faculty felt that the onus should be on the applicants to share their distance traveled somewhere in their application, if they would like it considered. Some faculty evinced that understanding an applicant’s distance traveled may be better appreciated during the interview. In sum, the DTQ was facilitated by the chair, the residency program director, and the director of equity, diversity, and inclusion, as well as by the diversity committee and our GME designated institutional officer, and their support was crucial in its implementation.

We needed to ensure that all applicants had the opportunity to view and answer the DTQ. To optimize awareness, all applicants received an email providing a web link to it. The instructions were also posted on our residency program website. Nonetheless, there are several reasons why students may not have provided a response: they did not feel comfortable sharing the information due to fear of bias; they felt that the information was already present in their application; they were unaware of the DTQ; they did not believe that the information would affect decision making; or they did not have time to participate.

The Association of American Medical Colleges recently developed a Supplemental ERAS application, first available during the 2022 cycle for some programs in some specialties. ¹⁰ The Supplemental ERAS allows applicants to describe their “most meaningful experiences and other impactful life events, if applicable.” ¹⁰ Otolaryngology–head and neck surgery programs have not yet begun participating in the Supplemental ERAS, though it appears to be a promising route for collecting data on distance traveled in the future.

Conclusion

We found that implementing an optional DTQ was feasible and that the majority of our faculty felt that it provided new and influential information beyond the ERAS application alone.