Upholding our PROMISE: Increased representation is not enough to foster belonging in graduate medical education

Abstract

PURPOSE: Sense of belonging supports academic achievement and encourages career endurance. The purpose of this study was to characterize what individual and institutional factors influence one's sense of belonging by describing the experiences of underrepresented in medicine (UIM) paediatric and internal medicine-paediatric residents in the United States. METHOD: The authors conducted a national survey of paediatric and internal medicine-paediatric residents. The 23-item anonymous web-based survey was distributed between October 2020 and January 2021 and included questions on socio-demographic characteristics and individual perceptions on sense of belonging, value, common mission or values at a program or institution and respect. The authors used linear mixed models and fitted regression models to examine individual factors and environmental factors that impact sense of belonging, value and respect. RESULTS: Across 29 residency programs, 938 (53%) of 1748 residents completed the survey. One hundred sixty-seven (18%) self-identified as UIM. UIM residents had a lower sense of belonging than non-UIM residents [mean (SD) 3.6 (0.87) vs. 4.0 (0.57)]. Black/AA and Hispanic/Latinx residents had the lowest sense of belonging [3.5 (0.82) and 2.8 (0.93), respectively]. UIM residents demonstrated decreased sense of belonging in programs that lacked bias training and where peers discriminated against them. Sense of belonging was increased in programs where they perceived a sense of support, respect or values alignment. Surprisingly, individual UIM resident sense of belonging was not improved by having more UIM residents in a program. CONCLUSION: UIM paediatric residents experience a decreased sense of belonging during training. Programs can support sense of belonging for UIM residents by demonstrating respect and support for them and by offering systems for bias training and reporting bias and discrimination. Recruiting a greater number of UIM trainees remains important; however, compositional diversity alone does not improve a sense of belonging for UIM residents. There is continued need for structural/institutional change, including addressing institutional culture and structural racism.

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