Presented at the Third Annual Barsan Emergency Medicine Research Forum

1. Underrepresented in Emergency
Medicine
Studying the Medical Education Pipeline
John Burkhardt, MD, MA

2. vToday’s Topic
Department of Emergency

3. vWhy Should You Care?
Department of Emergency
Patient care is negatively impacted by lack of
physician diversity

4. vDoes Medicine Reflect Society?
Department of Emergency

5. vU.S. Physicians by Race, Ethnicity, and Sex in 2013
Department of Emergency
Source: AAMC Data Warehouse
52006
22146
1455
17917
65096
1180
161402
67349
18353
2020
25768
216250
2681
302900
0 50000 100000 150000 200000 250000 300000 350000 400000 450000 500000
Asian (n=119,355)
Black or African-American (n=40,499)
American Indians or Alaska Native (n=3,475)
Hispanic or Latino (n=43,685)
Unknown (n=281,346)
Other Race (n=3,861)
White (=464,302)
Women Men

6. vU.S. Physicians by Graduation Year, Race, Ethnicity, and Sex (1980-2012)
Department of Emergency
Source: AAMC Data Warehouse
0
2000
4000
6000
8000
10000
12000
14000
Black or African American Women Black or African American Men
Hispanic or Latino Women Hispanic or Latino Men
American Indian or Alaska Native Women American Indian or Alaska Native Men
Asian Women Asian Men
White Women White Men

7. vUS Demographic Trends
Department of Emergency
An Overview of Racial and
Ethnic Demographic Trends."
National Research Council.
2001. America Becoming: Racial
Trends and Their Consequences,
Volume I. Washington, DC: The
National Academies Press. doi:
10.17226/9599.

8. vCensus vs US Medical School Graduates vs EM Applicants
Department of Emergency
Source: AAMC Data Warehouse, US Census
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
US Census Estimates 2016 (%) 2016-17 Graduates (%) 2017-18 EM Applicants (%)
Source: AAMC Data
Warehouse, US
Census

9. vCensus vs US Medical School Graduates vs EM Applicants
Department of Emergency
Source: AAMC Data Warehouse, US Census
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
US Census Estimates 2016 (%) 2016-17 Graduates (%) 2017-18 EM Applicants (%)
Women Men Source: AAMC Data
Warehouse, US Census

10. vSo What Are We Going to do About It?
Medical Education Pipeline
Department of Emergency
K-12 Education
Undergraduate
Education
Medical School Residency Practice

11. vSo What Are We Going to do About It?
Medical Education Pipeline
Department of Emergency
K-12 Education
Undergraduate
Education
Medical School Residency Practice

12. vWhere My Current Focus Is
Medical Education Pipeline
Department of Emergency
Medical
School
Residency Practice

13. vThe Medical School Effect
Department of Emergency
Entering
Career
Interest
Specialty
Choice
Medical School

14. vConceptual Framework
Department of Emergency
Societal Influence on
Criteria used to
Determine Perceived
Program Strength
Social Behaviors
Personal and
Cognitive
Limitations
Competing Values to
Maximize
Competing Values to Maximize
 Perceived Strength
 Curriculum
 "Fit"
 Location Desirability
 Career Track Alignment
 Cost
 Mentorship
Personal and Cognitive Limitations
 Social Replication of previous
student search behavior
 Belief in selectivity=superiority
 Limited information about
individual programs to make
rank list
 Limits on time for interviews
 Limits on programs able to
consider fully
Social Behaviors
 Adoption of similar questions and
social interactions so as not to be
judged negatively for departure
from normal
 Desire to be seen as in demand
but also specifically interested in
this program
 Peer modeling of behavior
reinforces normative approach
Societal Influence on Criteria used
to Determine Perceived Program
Strength
 Board Scores
 Research Productivity
 Associated with historically
strong institutions

15. vHypotheses
Lifestyle and future income will still matter
Female and URiM applicants will have a
lower likelihood of applying to emergency
medicine
A “Cooling Out” of women and URiM
students will be observed
Department of Emergency

16. vSo How Am I Going to Test That?
Department of Emergency
Matriculating
Questionnaire
AMCAS
Graduation
Questionnaire
ERAS
NBME AMA Masterfile

17. vAnalytical Approaches
Department of Emergency
Logistic Regression
Cluster Analysis
Panel Data Fixed Effects Model
Dominance Analysis

18. vModel Exploration
Department of Emergency
Model Model P
Value
Pseudo R-
Squared
Statistically Significant
Variables
Non-Significant
Variables
Observations in
Sub-Model
Demographics <0.001 0.0059 Gender, Age, URiM
Status
None 46,776
Attitudes <0.001 0.0702 Work-Life Balance,
Specialty
Competitiveness,
Specialty Personality,
Mentorship Advice, Debt
Level
Specialty Content,
Average Salary,
Family
Considerations
20,468
Debt Level <0.001 0.0070 Presence of Pre-Medical
Debt, Medical School
Debt, Non-Educational
Debt
Received Scholarship 50,061
Entering GPA <0.001 0.0034 Overall GPA, Science
GPA
None 49,435
Standardized Tests <0.001 0.0044 MCAT Total, Step 1
Score, Step 2 CK Score
None 49,455
Medical School
Activity
<0.001 0.0290 Number of Publications,
Research Experience,
Awarded AOA prior to
application, Confidence
in Specialty Choice,
Planned Practice with
Underserved
Populations
None 30,522

19. vStepwise Model Fitting
Department of Emergency
Demographics Demographics
and Attitudes
Demographics,
Attitudes, and
Debt
Demographics,
Attitudes, Debt,
and GPA
Demographics,
Attitudes, Debt,
GPA, and
Standardized
Tests
Demographics,
Attitudes, Debt,
GPA,
Standardized
Tests, and
Medical School
Experiences
Model P
Value
<0.001 <0.01 <0.001 <0.001 <0.001 <0.001
Pseudo R-
Squared
0.0059 0.0754 0.0799 0.0838 0.0880 0.1114
Available
Observations
46,776 18,531 17,944 17,364 16,898 16,875

20. vResults So Far…
Department of Emergency
VARIABLES Odds Ratio Logit coefficient 95% Confidence Interval
Female 0.78***
(0.049)
-0.25***
(0.062)
-0.370 - -0.125
Age in Years 1.03***
(0.011)
0.03***
(0.010)
0.014 - 0.054
URiM Status 0.81*
(0.086)
-0.21*
(0.106)
-0.419 - -0.004
Work Life Balance 2.18***
(0.090)
0.78***
(0.041)
0.698 - 0.859
Specialty Competitiveness 0.83***
(0.030)
-0.19***
(0.036)
-0.256 - -0.115
Specialty Personality 1.01
(0.075)
0.01
(0.074)
-0.134 - 0.157
Advice from Mentor 0.73***
(0.020)
-0.32***
(0.027)
-0.372 - -0.265
Importance of Debt 1.01
(0.035)
0.01
(0.035)
-0.061 - 0.077
Presence of Pre-Medical Debt 1.08
(0.067)
0.08
(0.062)
-0.047 - 0.197
Medical School Debt in $10,000 1.02***
(0.004)
0.02***
(0.004)
0.008 - 0.024
Non-Medical School Debt in $10,000 0.98
(0.021)
-0.02
(0.022)
-0.060 - 0.025
Cumulative Science GPA 1.00
(0.002)
0.00
(0.002)
-0.002 - 0.007
Cumulative Overall GPA 0.99**
(0.003)
-0.01**
(0.003)
-0.013 - -0.002
MCAT Total Score 1.03***
(0.009)
0.03***
(0.009)
0.012 - 0.046
USMLE Step 1 Score 0.99***
(0.002)
-0.01***
(0.002)
-0.019 - -0.009
USMLE Step 2 CK Score 1.01***
(0.002)
0.01***
(0.002)
0.006 - 0.014
Number of Publications 0.96***
(0.009)
-0.04***
(0.010)
-0.059 - -0.021
Has Research Experience 0.84***
(0.018)
-0.17***
(0.022)
-0.212 - -0.127
Awarded AOA prior to application 0.78*
(0.077)
-0.25*
(0.099)
-0.446 - -0.059
Confidence in Specialty Choice 1.38***
(0.079)
0.32***
(0.057)
0.209 - 0.433
Plan to Practice with Underserved
Populations
1.27***
(0.047)
0.24***
(0.037)
0.165 - 0.309
Constant 0.03***
(0.022)
-3.54***
(0.765)
-5.039 - -2.040

21. vResults So Far…
Department of Emergency
VARIABLES Odds Ratio Logit coefficient 95% Confidence Interval
Female 0.78***
(0.049)
-0.25***
(0.062)
-0.370 - -0.125
Age in Years 1.03***
(0.011)
0.03***
(0.010)
0.014 - 0.054
URiM Status 0.81*
(0.086)
-0.21*
(0.106)
-0.419 - -0.004
Work Life Balance 2.18***
(0.090)
0.78***
(0.041)
0.698 - 0.859
Specialty Competitiveness 0.83***
(0.030)
-0.19***
(0.036)
-0.256 - -0.115
Specialty Personality 1.01
(0.075)
0.01
(0.074)
-0.134 - 0.157
Advice from Mentor 0.73***
(0.020)
-0.32***
(0.027)
-0.372 - -0.265
Importance of Debt 1.01
(0.035)
0.01
(0.035)
-0.061 - 0.077
Presence of Pre-Medical Debt 1.08
(0.067)
0.08
(0.062)
-0.047 - 0.197
Medical School Debt in $10,000 1.02***
(0.004)
0.02***
(0.004)
0.008 - 0.024
Non-Medical School Debt in $10,000 0.98
(0.021)
-0.02
(0.022)
-0.060 - 0.025
Cumulative Science GPA 1.00
(0.002)
0.00
(0.002)
-0.002 - 0.007
Cumulative Overall GPA 0.99**
(0.003)
-0.01**
(0.003)
-0.013 - -0.002
MCAT Total Score 1.03***
(0.009)
0.03***
(0.009)
0.012 - 0.046
USMLE Step 1 Score 0.99***
(0.002)
-0.01***
(0.002)
-0.019 - -0.009
USMLE Step 2 CK Score 1.01***
(0.002)
0.01***
(0.002)
0.006 - 0.014
Number of Publications 0.96***
(0.009)
-0.04***
(0.010)
-0.059 - -0.021
Has Research Experience 0.84***
(0.018)
-0.17***
(0.022)
-0.212 - -0.127
Awarded AOA prior to application 0.78*
(0.077)
-0.25*
(0.099)
-0.446 - -0.059
Confidence in Specialty Choice 1.38***
(0.079)
0.32***
(0.057)
0.209 - 0.433
Plan to Practice with Underserved
Populations
1.27***
(0.047)
0.24***
(0.037)
0.165 - 0.309
Constant 0.03***
(0.022)
-3.54***
(0.765)
-5.039 - -2.040
Female 0.78***
(0.049)
-0.25***
(0.062)
-0.370 - -0.125
URiM Status 0.81*
(0.086)
-0.21*
(0.106)
-0.419 - -0.004
Work Life Balance 2.18***
(0.090)
0.78***
(0.041)
0.698 - 0.859
VARIABLES Odds Ratio Logit
coefficient
95%
Confidence
Interval
Plan to Practice with
Underserved
Populations
1.27***
(0.047)
0.24***
(0.037)
0.165 - 0.309

22. vDominance Analysis
Department of Emergency
Dominance Standardized Ranking
Stat. Domin. Stat.
Age 0.0029 0.0258 10
Work Life Balance 0.0490 0.4388 1
Specialty Competitive 0.0029 0.0260 9
Mentor Advice 0.0136 0.1216 2
MDDebt 0.0035 0.0315 7
Undergrad GPA 0.0026 0.0228 11
MCAT 0.0008 0.0075 14
Step 1 Score 0.0042 0.0380 6
Step 2 CK Score 0.0011 0.0095 13
Publications 0.0070 0.0626 4
Research Exp. 0.0129 0.1153 3
Choice Confidence 0.0035 0.0311 8
Underserved Practice 0.0048 0.0427 5
Gender 0.0025 0.0220 12
URiM 0.0006 0.0050 15

23. vPreliminary Conclusions
Work-Life Balance is still an important
consideration
Student mentorship and social justice interests
may be underutilized recruitment tools
Gender and URiM background decreases the
likelihood of a career in emergency medicine
- Even when other factors are also considered
Department of Emergency

24. vQuestions or Concerns
Department of Emergency

25. vReferences
1. CDC/National Center for Health Statistics. Emergency Department Visits. Center for Disease Control and Prevention;2015.
2. Joynt KE, Gawande AA, Orav E, Jha AK. Contribution of preventable acute care spending to total spending for high-cost medicare patients. JAMA. 2013;309(24):2572-2578.
3. McClelland M, Asplin B, Epstein SK, et al. The Affordable Care Act and emergency care. Am J Public Health. 2014;104(10):e8-10.
4. Twenge JM, Campbell WK, Carter NT. Declines in trust in others and confidence in institutions among American adults and late adolescents, 1972-2012. Psychol Sci. 2014;25(10):1914-
1923.
5. Rabovsky TM. Accountability in Higher Education: Exploring Impacts on State Budgets and Institutional Spending Patterns. Journal of Public Administration Research and Theory.
2012;22(4):675-700.
6. Cohen JJ. The consequences of premature abandonment of affirmative action in medical school admissions. JAMA. 2003;289(9):1143-1149.
7. Blume GH, Long MC. Changes in levels of affirmative action in college admissions in response to statewide bans and judicial rulings. Educational Evaluation and Policy Analysis.
2014;36(2):228-252.
8. Allen-Ramdial S-AA, Campbell AG. Reimagining the pipeline: advancing STEM diversity, persistence, and success. BioScience. 2014:biu076.
9. Hart LG, Skillman SM, Fordyce M, Thompson M, Hagopian A, Konrad TR. International medical graduate physicians in the United States: changes since 1981. Health Affairs.
2007;26(4):1159-1169.
10. Monroe A, Quinn E, Samuelson W, Dunleavy DM, Dowd KW. An Overview of the Medical School Admission Process and Use of Applicant Data in Decision Making: What Has Changed
Since the 1980s? Academic Medicine. 2013;88(5):672-681.
11. Association of American Medical Colleges. Table B3. Number of Active Residents, by Type of Medical School, GME Specialty, and Gender. Report on Residents 2016;
https://www.aamc.org/data/448482/b3table.html, 2016.
12. National Resident Matching Program. 2017 Main Residency Match Calendar. 2017; http://www.nrmp.org/residency/main-match-events/. Accessed January, 2017.
13. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. Jama-J Am Med Assoc. 2008;300(10):1154-1164.
14. Boyd JS, Clyne B, Reinert SE, Zink BJ. Emergency Medicine Career Choice: A Profile of Factors and Influences from the Assoication of American Colleges (AAMC) Graduation
Questionnaires. Academic Emergency Medicine. 2009;16(6):544-549.
15. Svirko E, Lambert T, Brand L, Goldacre MJ. Career choices for emergency medicine: national surveys of graduates of 1993-2009 from all UK medical schools. Emergency medicine
journal : EMJ. 2013.
16. Scott IM, Abu-Laban RB, Gowans MC, Wright BJ, Brenneis FR. Emergency medicine as a career choice: a descriptive study of Canadian medical students. Can J Emerg Med.
2009;11(3):196-206.
17. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004.
Acad Med. 2005;80(9):809-814.
18. Goldcare MJ, Goldcare R, Lambert TW. Doctors who considered but did not pursue specific clinical specialites as careers: questionnaire surveys. Journal of the Royal Society of
Medicine. 2012;105:166-176.
19. Scott IM, Wright BJ, Brenneis FR, Gowans MC. Whether or wither some specialties: a survey of Canadian medical student career interest. BMC Med Educ. 2009;9(57):57.
20. Newton DA, Grayson MS. Trends in Career Choice by US Medical Schol Graduates. JAMA. 2003;290(9):1179-1182.
21. Marshall RJ, Jr., Fulton JP, Wessen AF. Physician career outcomes and the process of medical education. J Health Soc Behav. 1978;19(2):124-138.
22. Baldwin A, Woods K, Simmons MC. Diversity of the allied health workforce: the unmet challenge. J Allied Health. 2006;35(2):116-120.
23. Rhodes PJ. The career aspirations of women dcotrs who qualified in 1974 and 1977 from a United Kingdom medical school. Medical Education. 1989;23:125-135.
24. Maggio LA, Tannery NH, Chen HC, ten Cate O, O'Brien B. Evidence-Based Medicine Training in Undergraduate Medical Education: A Review and Critique of the Literature ublished
2006-2011. Acad Med. 2013;88(7):1022-1028.
Department of Emergency

26. vReferences
25. Chaffee EE. Rational Decisionmaking in Higher Education. National Center for Higher Education Management;1983.
26. Jones BD. Bounded rationality. Annu Rev Polit Sci. 1999;2:297-321.
27. Betz N, Hackett G. Applications of Self-Efficacy Theory to Understanding Career Choice Behavior. Journal of Social and Clinical Psychology. 1986;4(8):279-289.
28. Lent RW, Brown SD, Larkin KC. Self-Efficacy in the Prediction of Academic Performance and Perceived Career Options. Journal of Counseling Psychology. 1986;33(3):265-269.
29. Krumbotlz JD, Mitchell AM, Jones GB. A Social Learning Theory of Career Selection. The Counseling Psychologist. 1976;6(71):71-81.
30. Hopson L, Losman E, Stansfield RB, Vohra T, Turner-Lawerence D, Burkhardt J. The Multiple Mini Interview (MMI) for Emergency Medicine Resident Selection. Journal of Emergency Medicine.
2014;46:537-543.
31. Sullivan L. Missing Persons: Minorities in Health Professions, A Report of the Sullivan Commission on Diversity in the Healthcare Workforce. W. K. Kellogg Foundation;2004.
32. Landry AM, Stevens J, Kelly SP, Sanchez LD, Fisher J. Under-represented minorities in emergency medicine. The Journal of emergency medicine. 2013;45(1):100-104.
33. Thurmond VB, Cregler LL. Why Students Drop Out of the Pipeline to Health Professions Careers: A Follow-up of Giften Minority High School Students. Acad Med. 1999;74(4):448-451.
34. DeVille K, Kopelman L. Diversity, Trust, and Patient Care: Affirmative Action in Medical Education 25 years After Bakke. Journal of Medicine and Philosophy. 2003;28(4):489-516.
35. US Department of Health and Human Services. The Rationale for Diversity in the Health Professions: A Review of the Evidence. US Department of Health and Human Services;2006.
36. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in US Medical Schools. Journal of the American Medical
Association. 2008;300(10):1135-1145.
37. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. US residency training before and after the 1997 Balanced Budget Act. JAMA. 2008;300(10):1174-1180.
38. National Resident Matching Program. Results and Data: 2012 Main Residency Match. Washington, D.C.: National Resident Matching Program;2012.
39. Association of American Medical Colleges. Physician Shortages to Worsen Without Increases in Residency Training. June 2010.
40. Burkhardt JC. Decision-Making by Admissions Officers in Medical School: Gatekeepers to the Profession. University of Michigan; 2015.
41. Bruhn JG, Parsons OA. Medical Student Attitudes toward Four Medical Specialties. Academic Medicine. 1964;39(1):40-49.
42. Carline JD, Greer T. Comparing physicians' specialty interests upon entering medical school with their eventual practice specialties. Academic Medicine. 1991;66(1):44-46.
43. Compton MT, Frank E, Elon L, Carrera J. Changes in US medical students’ specialty interests over the course of medical school. Journal of general internal medicine. 2008;23(7):1095-1100.
44. Lieu TA, Schroeder SA, Altman DF. Specialty choices at one medical school: recent trends and analysis of predictive factors. Academic Medicine. 1989;64(10):622-629.
45. Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. Canadian Medical Association
Journal. 2004;170(13):1920-1924.
46. Bandura A. Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review. 1977;84(2):191-215.
47. Wendel TM, Godellas CV, Prinz RA. Are there gender differences in choosing a surgical career? Surgery. 2003;134(4):591-596.
48. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: Gender or generation? Archives of Surgery. 2006;141(11):1086-
1094.
49. Lambert EM, Holmboe ES. The Relationship between Specialty Choice and Gender of U.S. Medical Students, 1990–2003. Academic Medicine. 2005;80(9):797-802.
50. Diderichsen S, Johansson EE, Verdonk P, Lagro-Janssen T, Hamberg K. Few gender differences in specialty preferences and motivational factors: a cross-sectional Swedish study on last-year
medical students. BMC Medical Education. 2013;13(1):39.
51. Wright AL, Schwindt LA, Bassford TL, et al. Gender differences in academic advancement: patterns, causes, and potential solutions in one US College of Medicine. Academic Medicine.
2003;78(5):500-508.
52. Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA. Gender differences in the salaries of physician researchers. Jama. 2012;307(22):2410-2417.
53. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. Jama. 2008;300(10):1154-1164.
54. Stratton TD, McLaughlin MA, Witte FM, Fosson SE, Nora LM. Does students' exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency
program selection? Academic Medicine. 2005;80(4):400-408.
55. Burkhardt JC, Smith-Coggins R, Santen S. Residents values in a rational decision-making model: an interest in academics in emergency medicine. Intern Emerg Med. 2016;11(7):993-997.
Department of Emergency

27. vReferences
56. Peterson WJ, Hopson LR, Khandelwal S, et al. Impact of Doximity Residency Rankings on Emergency Medicine Applicant Rank Lists. Western Journal of Emergency Medicine. 2016;0(0).
57. Association of American Colleges. Electronic Residency Application Service. 2015; https://www.aamc.org/services/eras/, 2016.
58. Silverberg M, Weizberg M, Murano T, Smith JL, Burkhardt JC, Santen SA. What is the prevalence and success of remediation of Emergency Medicine residents? Western Journal of
Emergency Medicine. 2015;0(0).
59. O'Neill LD, Wallstedt B, Eika B, Hartvigsen J. Factors associated with dropout in medical education: a literature review. Med Educ. 2011;45(5):440-454.
60. Allen D. The Locus of Preparation and Privilege: College Choice and Social Reproduction [Doctoral]. Chicago, IL: Higher Education, Loyola University Chicago; 2012.
61. Din KA. Asian Pacific Islander Americans and Affirmative Negative Action. The Vermont Connection. 2015;33(1):4.
62. Staats CA, K.; Wright, R.A.; Jackson, V.W. State of the Science: Implicit Bias Review. Kirwan Institute;2016.
63. Grewal D, Ku MC, Girod SC, Valantine H. How to Recognize and Address Unconscious Bias. In: Roberts LW, ed. The Academic Medicine Handbook: A Guide to Achievement and
Fulfillment for Academic Faculty. New York, NY: Springer New York; 2013:405-412.
64. Bertrand M, Mullainathan S. Are Emily and Greg More Employable than Lakisha and Jamal? A Field Experiment on Labor Market Discrimination. The American Economic Review.
2004;94(4):991-1013.
65. Bendick M, Nunes AP. Developing the Research Basis for Controlling Bias in Hiring. Journal of Social Issues. 2012;68(2):238-262.
66. Burkhardt JC. What Can We Learn From Resident Selection Interviews? Journal of Graduate Medical Education. 2015;7(4):673-675.
67. Burkhardt JC, Stansfield RB, Vohra T, Losman E, Turner-Lawrence D, Hopson LR. Prognostic Value of the MULTIPLE MINI-INTERVIEW for Emergency Medicine Residency Performance.
The Journal of emergency medicine. 2015;In Press.
68. Stephenson-Famy A, Houmard BS, Oberoi S, Manyak A, Chiang S, Kim S. Use of the Interview in Resident Candidate Selection: A Review of the Literature. Journal of Graduate Medical
Education. 2015.
69. Karen D. Toward a Political-Organizational Model of Gatekeeping: The Case of Elite Colleges. Sociology of Education. 1990;63(4):227-240.
70. Alon S. The Evolution of Class Inequality in Higher Education: Competition, Exclusion, and Adaptation. American Sociological Review. 2009;74(5):731-755.
71. Rivera L. Ivies, extracurriculars, and exclusion: Elite employers' use of educational credentials. Research in Social Stratification and Mobility. 2011;29:71-90.
72. Edwards JC, Elam CL, Wagoner NE. An admission model for medical schools. Acad Med. 2001;76(12):1207-1212.
73. Axelson RD, Kreiter CD. Rater and occasion impacts on the reliability of pre-admission assessments. Med Educ. 2009;43(12):1198-1202.
74. Edwards JC, Johnson EK, Molidor JB. The interview in the admission process. Acad Med. 1990;65(3):167-177.
75. Love JN, Howell JM, Hegarty CB, et al. Factors that influence medical student selection of an emergency medicine residency program: implications for training programs. Acad Emerg Med.
2012;19(4):455-460.
76. Razack S, Hodges B, Steinert Y, Maguire M. Seeking inclusion in an exclusive process: discourses of medical school student selection. Med Educ. 2015;49(1):36-47.
77. Association of American Colleges. Medical School Admission Requirments. 2015; https://www.aamc.org/students/applying/requirements/msar/. Accessed July, 2015.
78. Raferty AE, Hout M. Maximally Maintained Inequality: Expansion, Reform, and Opportunity in Irish Education. Sociology of Education. 1993;66(1):41-62.
79. Berner ES, Brooks CM, Erdmann JB. Use of the USMLE to select residents. Academic Medicine. 1993;68(10):753-759.
80. Swanson DB, Sawhill A, Holtzman KZ, et al. Relationship Between Performance on Part I of the American Board of Orthopaedic Surgery Certifying Examination and Scores on USMLE
Steps 1 and 2. Academic Medicine. 2009;84(10):S21-S24.
81. Thundiyil JG, Modica RF, Silvestri S, Papa L. Do United States Medical Licensing Examination (USMLE) Scores Predict In-Training Test Performance for Emergency Medicine Residents?
The Journal of emergency medicine. 2010;38(1):65-69.
82. Rifkin WD, Rifkin A. Correlation between housestaff performance on the United States Medical Licensing Examination and standardized patient encounters. Mt Sinai J Med. 2005;72(1):47-
49.
83. Ruddy MP, Eubanks JEJ, Farrell MEI. More About the Role of USMLE Step 1 Scores in Resident Selection. Academic Medicine. 2016;91(11):1468-1469.
Department of Emergency

28. vDemographics
Department of Emergency
Number (%) Mean (SD)
Interest in EM 4,140 (8.1%) Age 28.7 (3.7)
Interest Outside EM 47,242 (91.9%) Total GPA 3.54 (36.0)
Male 55,486 (52.1%) Science GPA 3.61 (29.6)
Female 51,038 (47.9%) MCAT Total 29.7 (4.3)
URiM 82,709 (85.9%) USMLE Step 1 Score 220.6 (20.2)
Non-URiM 13,557 (14.1%) USMLE Step 2 CK Score 225.4 (22.0)
Elected to AOA at time of
Application
14, 188 (13.1%) Publication and Other
Scholarly Outputs
2.5 (4.6)
Not AOA 94,337 (86.9%) Research Experiences 2.1 (1.8)
Importance of Factor Observations
Work-Life Balance 20,693 No Influence Minor Influence Moderate Influence Strong Influence
Specialty
Competitiveness
51,383 1,936 (9.4%) 3,823 (18.5%) 7,170 (34.7%) 7,764 (37.5%)
Specialty Personality 30.658 19,331 (37.6%) 14,587 (28.4%) 13,657 (26.6%) 3,808 (7.4%)
Specialty Content 30,643 222 (0.7%) 681 (2.2%) 4,216 (13.8%) 25,539 (83.3%)
Average Salary 51,386 196 (0.6%) 706 (2.3%) 5,216 (17.0%) 24,525 (80.0%)
Mentor Advice 51,340 11,296 (22.0%) 16,394 (31.9%) 17,546 (34.2%) 6,150 (12.0%)
Family Expectations 51,358 21,270 (41.4%) 12,353 (24.1%) 11,539 (22.5%) 6,196 (12.1%)
Debt Level 51,353 26,426 (51.5%) 12,262 (23.9%) 8,693 (16.9%) 3,972 (7.7%)

29. vResults Revisited
Department of Emergency
Female 0.78***
(0.049)
-0.25***
(0.062)
-0.370 - -0.125
Age in Years 1.03***
(0.011)
0.03***
(0.010)
0.014 - 0.054
URiM Status 0.81*
(0.086)
-0.21*
(0.106)
-0.419 - -0.004
Work Life Balance 2.18***
(0.090)
0.78***
(0.041)
0.698 - 0.859
Specialty Competitiveness 0.83***
(0.030)
-0.19***
(0.036)
-0.256 - -0.115
Specialty Personality 1.01
(0.075)
0.01
(0.074)
-0.134 - 0.157
Advice from Mentor 0.73***
(0.020)
-0.32***
(0.027)
-0.372 - -0.265
Importance of Debt 1.01
(0.035)
0.01
(0.035)
-0.061 - 0.077
Presence of Pre-Medical Debt 1.08
(0.067)
0.08
(0.062)
-0.047 - 0.197
Medical School Debt in $10,000 1.02***
(0.004)
0.02***
(0.004)
0.008 - 0.024
Non-Medical School Debt in $10,000 0.98
(0.021)
-0.02
(0.022)
-0.060 - 0.025
Cumulative Science GPA 1.00
(0.002)
0.00
(0.002)
-0.002 - 0.007
Cumulative Overall GPA 0.99**
(0.003)
-0.01**
(0.003)
-0.013 - -0.002
MCAT Total Score 1.03***
(0.009)
0.03***
(0.009)
0.012 - 0.046
USMLE Step 1 Score 0.99***
(0.002)
-0.01***
(0.002)
-0.019 - -0.009
USMLE Step 2 CK Score 1.01***
(0.002)
0.01***
(0.002)
0.006 - 0.014
Number of Publications 0.96***
(0.009)
-0.04***
(0.010)
-0.059 - -0.021
Has Research Experience 0.84***
(0.018)
-0.17***
(0.022)
-0.212 - -0.127
Awarded AOA prior to application 0.78*
(0.077)
-0.25*
(0.099)
-0.446 - -0.059
Confidence in Specialty Choice 1.38***
(0.079)
0.32***
(0.057)
0.209 - 0.433
Plan to Practice with Underserved Populations 1.27***
(0.047)
0.24***
(0.037)
0.165 - 0.309
Constant 0.03***
(0.022)
-3.54***
(0.765)
-5.039 - -2.040

30. vDominance Analysis
Department of Emergency
Dominance Standardized Ranking
Stat. Domin. Stat.
Age 0.0029 0.0258 10
Work Life Balance 0.0490 0.4388 1
Specialty Competitive 0.0029 0.0260 9
Mentor Advice 0.0136 0.1216 2
MDDebt 0.0035 0.0315 7
Undergrad GPA 0.0026 0.0228 11
MCAT 0.0008 0.0075 14
Step 1 Score 0.0042 0.0380 6
Step 2 CK Score 0.0011 0.0095 13
Publications 0.0070 0.0626 4
Research Exp. 0.0129 0.1153 3
Choice Confidence 0.0035 0.0311 8
Underserved Practice 0.0048 0.0427 5
Gender 0.0025 0.0220 12
URiM 0.0006 0.0050 15