Introduction

Representation of female and minority physicians varies across specialties and may influence career selection by medical students [1, 2].The importance of role models may be magnified for females and underrepresented minorities (URM) who face unique challenges such as overcoming gender biases/discrimination, and the need to explain the context and nuances of their lived experiences [3, 4].

Female students are more likely to pursue primary care specialties than males [5]. Gender discrimination, lack of training support, and mentorship have been cited as contributing factors to the continued underrepresentation of female physicians in specialties such as surgical fields [3]. Studies have also shown that female students are more likely than males to enter programs with higher proportions of female residents [1] and that URM students are more likely to apply to specialties with a higher proportion of racially concordant practicing physicians [6]. When compared to their peers, URM students place significant importance on having a mentor of the same race or ethnicity when pursuing training in competitive fields like urology [4]. Conversely, they may be deterred from other fields such as interventional radiology, when they perceive a lack of ethnic diversity in training [7].

The nature of interpersonal relations during the clerkship experience has been identified as an important contributor to residency selection for 70% of students, especially those involving positive interactions with attendings and residents [5]. Exposure to role model physicians during clinical clerkships has also been identified as an important modifier of postgraduate specialty selection by medical students who ultimately select primary care, surgical, and ROAD (radiology, ophthalmology, anesthesiology, and dermatology) specialties [8, 9].

While other studies address the impact of clerkship experiences and role models met during clerkships on specialty selection, there is a lack of data regarding the impact of concordant demographics during clerkship experiences on specialty selection. To further investigate the effect of demographic concordance between medical students and clerkship role models on specialty selection, we conducted a survey of graduating medical students to assess the perceived importance and influence of third-year clerkship experiences with demographically concordant physicians in the selection of specialty for post-graduate training.

Materials and Methods

In July and September of 2022, an 11-question Qualtrics® survey was circulated nationally to 4th year medical students (Class of 2023) via a national group messaging system and email of the Organizational Student Representatives (OSR) of the Association of American Medical Colleges (AAMC). While OSR representatives at all Canadian, Caribbean, and U.S. osteopathic and allopathic medical schools were asked to forward the recruitment email and survey link to their respective classes, the precise count of participating schools and students receiving the survey is unknown. Participation in the survey was voluntary and responses were collected anonymously. In addition to demographic factors, the survey gathered information regarding specialty of choice; extent of exposure to preceptors of the same gender, race, or ethnicity during clinical clerkships; and the perceived importance and influence of those interactions (Likert 1–5, Low—High) on specialty selection. This data was stratified by gender, race, ethnicity, and specialty choice. Descriptive analysis was used to assess sample characteristics. Bivariate analysis was performed using chi-squared for discrete variables (gender, race, ethnicity, specialty), independent t-tests for continuous variables (Likert scores), and ANOVA single-factor analysis for between-group analysis (Microsoft Excel). Institutional Review Board approval for this study was obtained through Florida International University (IRB #22–0344).

Results

A total of 84 students responded to the survey. As shown in Table 1, the average age of respondents was 26 years old (SD 1.9 years) and 64% of respondents identified as female (vs. 35% male and 1% non-binary). Most respondents identified as Caucasian (58%), followed by Latino/Hispanic (15.5%), Asian (12%) and African-American (10%).

Table 1 Participant Characteristics (N = 84)
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Of the 54 female respondents (64%), 31 (57%) identified as Caucasian, 9 (17%) Asian, 7 (13%) Latino/Hispanic, 5 (9%) African-American, and 1 (2%) Middle Eastern. Of the 29 male respondents (35%), 17 (59%) identified as Caucasian, 6 (21%) Latino/Hispanic, 4 (14%) African American, 1 (3%) Middle Eastern, and 1 (3%) Asian. One student identified as non-binary (Caucasian). For further analysis, students who identified as both Caucasian and another race/ethnicity were included in the non-Caucasian group (n = 5).

As shown in Table 2, specialties most highly represented included Pediatrics (16%), Internal Medicine (14%), Obstetrics and Gynecology (13%), Psychiatry (10%), and Emergency Medicine (7%). Caucasian females’ most common specialties of choice were pediatrics (n = 9/31, 29%), obstetrics-gynecology (n = 6/31, 19%), and psychiatry (n = 4/31, 13%). Non-Caucasian females most common specialties of choice were internal medicine (n = 8/23, 39%), dermatology (n = 3/23, 13%), psychiatry (n = 2/23, 9%) and obstetrics-gynecology (n = 2/23, 9%). Caucasian males’ most common specialties of choice were emergency medicine (n = 4/17, 24%), pediatrics (n = 3/17, 18%), and diagnostic radiology (n = 3/17, 18%). Non-Caucasian males’ most common specialties of choice were internal medicine (n = 3/1, 25%), obstetrics-gynecology (n = 2/12, 17%), psychiatry (n = 2/12, 17%), and anesthesiology (n = 2/12, 17%).

Table 2 Participants by Residency Choice
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As shown in Fig. 1, female students ascribed more importance to gender concordance with preceptors on the third-year clerkship most associated with their specialty of choice than their male counterparts [3.4 (SD 1.2) vs. 1.3 (SD 0.8) respectively, p < 0.0001]. Female students also attributed greater influence to gender concordance on their final specialty selection than males [2.37 (SD 1.1) vs. 1.31 (SD 0.8) respectively, p < 0.0001].

Fig. 1
figure 1

Perceived importance attributed to gender concordance with preceptors on the third year clerkship most associated with specialty of choice and perceived influence of gender concordance on final specialty selection

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As shown in Fig. 2, students identifying as non-Caucasian ascribed more importance to race/ethnicity concordance with preceptors on the third-year clerkship most associated with their specialty of choice than their Caucasian counterparts [2.8 (SD 1.4) vs. 1.2 (SD 0.5) respectively, p < 0.0001, Fig. 2A] with African American students ascribing the greatest importance [3.2 (SD 1.6)], followed by Asian students [2.7 (SD 1.3)], and Latino/Hispanic students [2.6 (SD 1.3), p < 0.0001, Fig. 2B]. Students identifying as non-Caucasian also attributed greater influence to this race/ethnicity concordance on their final specialty selection than Caucasians [2.0 (SD 1.3) vs. 1.1 (SD 0.4) respectively, p < 0.0001, Fig. 2C] with Asian students ascribing the greatest influence [2.3 (SD 1.7)], followed by African-American students [2.1 (SD 1.5)], and Middle Eastern students [2.0 (SD 1.4), p < 0.001, Fig. 2D].

Fig. 2
figure 2

Perceived importance attributed to race/ethnicity concordance with preceptors on the third year clerkship most associated with specialty of choice (overall a and stratified b) and perceived influence of race/ethnicity concordance on specialty choice (overall c and stratified d)

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Students identifying as Caucasian females ascribed the greatest importance to gender concordance with preceptors on the third-year clerkship most associated with their specialty of choice [3.5 (SD 1.2)], followed by non-Caucasian females [3.3, (SD 1.2)], Caucasian males [1.4 (SD 0.7)], and non-Caucasian males [1.3 (SD 0.9), p < 0.0001]. No significant difference was found between Caucasian females and non-Caucasian females [3.5 (SD 1.2) vs. 3.3 (SD 1.2), p = 0.25] or between Caucasian males and non-Caucasian males [1.4 (SD 0.7) vs. 1.3 (SD 0.9), p = 0.3, Fig. 3A]. Non-Caucasian females ascribed the greatest influence of gender concordance on final specialty selection [2.4 (SD 1.2)] followed by caucasian females [2.4 (SD 1.0)], non-Caucasian males [1.4 (SD 1.0)], and Caucasian males [1.2 (SD 0.6), p < 0.001]. No significant difference was found between Caucasian females and non-Caucasian females [2.4 (SD 1.0) vs. 2.4 (SD 1.2), p = 0.45] or between Caucasian males and non-Caucasian males [1.2 (SD 0.6) vs. 1.4 (SD 1.0), p = 0.29, Fig. 3B].

Fig. 3
figure 3

Perceived importance attributed to gender concordance with preceptors on the third year clerkship most associated with specialty of choice (a) and perceived influence of gender concordance on specialty choice (b)

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Students identifying as non-Caucasian females ascribed the greatest importance to race/ethnicity concordance with preceptors on the third-year clerkship most associated with their specialty of choice [3.2 (SD 1.2)], followed by non-Caucasian males [(2.1 (SD 1.3)], Caucasian females [(1.2, (SD 0.6)], and Caucasian males [(1.2 (SD 0.4), p < 0.0001, Fig. 4A]. A significant difference was found between Caucasian females and non-Caucasian females [1.2 (SD 0.6) vs. 3.2 (SD 1.2), p < 0.0001] and between Caucasian males and non-Caucasian males [1.2 (SD 0.4) vs. 2.1 (SD 1.3), p = 0.025, Fig. 4A]. Non-Caucasian females also ascribed the greatest influence of race/ethnicity concordance on final specialty selection [2.3 (SD 1.3)] followed by non-Caucasian males [1.5 (SD 1.2)], Caucasian females [1.2 (SD 0.6)], and Caucasian males [1.1 (SD 0.2), p < 0.0001, Fig. 4B]. A significant difference was found between Caucasian females and non-Caucasian females [1.2 (SD 0.6) vs. 2.3 (SD 1.3), p = 0.0004] but not between Caucasian males and non-Caucasian males [1.1 (SD 0.2) vs. 1.5 (SD 1.2), p = 0.12, Fig. 4B].

Fig. 4
figure 4

Perceived importance attributed to race/ethnicity concordance with preceptors on the third year clerkship most associated with specialty of choice (a) and perceived influence of race/ethnicity concordance on specialty choice (b)

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Discussion

Our findings support prior reports on the importance of gender and race/ethnicity diversity of clinical mentorship [10,11,12]. Although previous studies have highlighted the significance of clerkship experiences and the influence of role models encountered during clerkships on specialty selection [5, 8], none that we have encountered explores the impact of demographic concordance between students and clerkship preceptors on specialty choice. Our study found that gender and race/ethnicity concordance between students and clinical preceptors is perceived as especially important and influential in specialty selection by minority and female medical students. With increasing numbers of female and URM students, these findings highlight the importance of diversity in gender and race/ethnicity representation by preceptors on clinical clerkships.

Non-Caucasian students attributed greater importance to race/ethnicity concordance than their Caucasian peers and female students attributed greater importance to gender concordance than their male peers. Notably, non-Caucasian females ascribed the greatest influence of both gender-concordance and race/ethnicity concordance on third-year clerkships in relation to specialty selection, suggesting that mentorship is especially valuable to this historically underrepresented group.

Because the medical field was historically dominated by Caucasian males, females and URM students may value gender and race/ethnicity concordance as a source of representation and guidance. These trends were found to be most pronounced for non-Caucasian females, where concordance of gender and/or race/ethnicity may help to address dual barriers. Because interactions between medical students and clinical preceptors may evolve into mentoring relationships or other long-lasting professional connections, the absence of female and/or URIM role models encountered on clinical clerkships may also significantly compromise future opportunities for professional development, thereby exacerbating the progressively larger underrepresentation of these groups seen at higher levels of academic advancement [13].

Our findings may reflect the unique challenges and experiences faced by female and URM medical students who are most likely to encounter implicit bias and/or frank discrimination in the medical education environment [14]. Connecting with preceptors who share a similar demographic profile may offer these students a valuable source of support and mentorship.

Diversity in the healthcare workforce has been shown to improve medical outcomes and enhance physician–patient relationships [15, 16]. Our findings that gender and race/ethnicity concordance is perceived as especially important and influential in specialty selection by minority and female medical students further supports the need to recruit and retain a diverse faculty. Strategies to recruit a diverse physician workforce might include (but are not limited to) inclusive job advertisements, providing implicit bias training, employing equitable candidate search strategies, conducting impartial evaluations of applications, and establishing diverse hiring committees [17, 18]. Equally important to introducing diversity into the physician workforce is the implementation of strategies for retaining URM physicians. These strategies might include microaggression training, robust well-being resources, the allocation of dedicated funding for diversity councils, and the implementation of effective feedback mechanisms to address challenges faced by URM physicians in their daily work environment [18].

This study is limited by its small sample size and potential responder bias and therefore may not accurately represent the population intended to be surveyed. However, it does provide important insights which may be used to foster a more inclusive clinical learning environment. In addition, while respondents reported high levels of perceived influence of demographic concordance with preceptors on final specialty selection, this study did not address if students actually chose specialties where they experienced concordance with preceptors at a higher rate than students who did not experience concordance. This study also does not address all underrepresented groups in medicine (i.e. American Indians and LGBTQ-identifying individuals), though similar results might be expected. Future studies should aim to address these additional URM populations, to verify perceived influence, and to quantify the impact of demographic concordance during medical school on career advancement.

Conclusion

We found that gender and race/ethnicity concordance is perceived as especially important and influential in specialty selection by minority and female medical students. In order to best support these students, further diversify medical specialties, and reduce underrepresentation in advancement, it is important that academic institutions recruit and retain a diverse faculty.