Mohs micrographic surgery is a highly precise technique for treating skin cancer. Surgeons remove visible tumor in thin layers, examine each layer under a microscope in real time, and continue excising until the margins are completely clear of cancer cells. The approach spares healthy tissue while maximizing cure rates, which is why it has become the standard of care for many high-risk skin cancers, including melanomas and aggressive basal and squamous cell carcinomas on the face and other cosmetically and functionally critical sites. Training in this field is exceptionally competitive: after dermatology residency, physicians must match into a dedicated fellowship, now formally designated micrographic surgery and dermatologic oncology, or MSDO. Whoever leads those fellowship programs effectively controls the gatekeeping of the entire subspecialty workforce.

The researchers asked a deceptively simple question: has the population of people entering and leading these programs become more representative of the United States over the past quarter century? To answer it, they compiled rosters of fellows and program directors across the two study periods and quantified the proportions of Asian, Black, Hispanic and White individuals in each group, then tested whether the differences between eras reached statistical significance. The data source was the public directory of fellowship training maintained by the American College of Mohs Surgery, which lists trainees and program leadership over time.

Among fellows, the clearest signal was a significant rise in Asian representation. In the 1996 to 2000 cohort, 25.1 percent of Mohs fellows were Asian; by 2021 to 2025, that figure had climbed to 32.6 percent, a statistically significant increase. The proportions of Black fellows (16.4 percent versus 12.6 percent), Hispanic fellows (7.2 percent versus 8.4 percent) and White fellows (51.3 percent versus 46.4 percent) shifted in both directions across the decades, but none of those changes was statistically significant. Taken together, non-White fellows rose from 48.7 percent of the earlier cohort to 53.6 percent of the recent one, an aggregate gain that also fell short of statistical significance.

The leadership picture told a more dynamic story. The proportion of Asian program directors increased significantly, from 15.5 percent in 1996 to 2000 to 25.2 percent in 2021 to 2025. Hispanic directors also rose significantly, from 1.4 percent to 4.5 percent. Meanwhile, the share of White program directors declined significantly, from 70.4 percent to 54.1 percent. Black representation among directors moved from 12.7 percent to 16.2 percent, but this change was not statistically significant. In other words, the leadership of MSDO fellowships has diversified meaningfully over three decades, yet the gains have been concentrated in specific groups rather than distributed evenly across all communities underrepresented in medicine.

Why does the demographic makeup of a surgical subspecialty matter for patients? The authors point to a substantial body of evidence linking patient-physician concordance, the degree to which patients and doctors share personal or ethnic dimensions of identity, with trust, communication quality, satisfaction and clinical outcomes. Skin cancer is an area where this matters acutely. Dermatologic oncology care involves decisions about disfiguring surgery on visible parts of the body, and patients from historically marginalized groups have documented reasons for wariness toward a medical system that has not always served them equitably. A workforce in which patients can more often see their own experiences reflected may improve rapport, adherence to surveillance and, ultimately, outcomes in skin cancer care. Representation among the educators who train the next generation compounds this effect, because program directors shape not only who enters the field but also the culture, mentorship networks and recruitment practices of the specialty.

The study’s central caveat is methodological, and the authors are unusually candid about it. For most of the thirty-year study period, self-reported racial and ethnic backgrounds of fellows and directors were simply not available. To fill the gap, the researchers used a name-based inference approach, employing the rethnicity R package, a tool that predicts race and ethnicity from personal names using probabilistic statistical models. The method has been validated on large voter registration datasets and demonstrates strong predictive accuracy, but its probabilistic design means misclassifications are inevitable, particularly for individuals whose names do not conform to common patterns associated with particular groups.

To gauge how much error this introduces, the team validated the name-based predictions against self-reported data from the Accreditation Council for Graduate Medical Education, or ACGME, for the overlapping 2011 to 2025 period. The comparison showed directionally consistent trends, meaning the inferred data captured the same overall patterns as the self-reported figures, but with a mean absolute difference of 10.5 percentage points. That is a substantial margin, and it means the specific percentages reported in the study should be read as estimates of magnitude rather than exact counts. Still, the authors argue, name-based inference provides a practical and reproducible way to evaluate datasets when self-reported demographic data are unavailable, opening a window on longitudinal trends that would otherwise remain entirely unexamined. Without such methods, the demographic history of the MSDO pipeline from the 1990s onward would be largely invisible.

The broader context of the findings is a specialty that continues to grow in scope and importance. Skin cancer incidence in the United States remains high, and Mohs surgery has expanded accordingly, making the demographic trajectory of its workforce a matter of increasing public health relevance. Prior research cited by the authors has documented the low diversity of the broader Mohs workforce, examined trends in matching among underrepresented minority applicants, and identified barriers that deter such applicants from pursuing the fellowship in the first place. The new report adds a longitudinal dimension to that literature, showing that while the leadership tier has diversified significantly, the fellowship cohort itself has not changed in ways that reach statistical significance for most groups.

The bottom line, the authors conclude, is that representation of individuals underrepresented in medicine among MSDO fellows and fellowship directors remains persistently low, and that efforts to diversify the pipeline must remain a priority as the specialty continues to expand. The significant gains among Asian and Hispanic program directors demonstrate that change is possible within a single generation of leadership, but the flat trends for Black fellows and the modest, statistically insignificant shifts elsewhere suggest that structural barriers in recruitment, mentorship and access to the specialty have not dissolved on their own. As Mohs surgery takes on a growing share of the nation’s skin cancer burden, the demographic composition of the surgeons who perform it, and of the educators who train them, will increasingly shape who trusts, seeks and receives the highest standard of dermatologic oncology care.

Subject of Research: Racial and ethnic diversity trends among Mohs micrographic surgery and dermatologic oncology fellows and fellowship directors

Article Title: Trends in racial and ethnic diversity among micrographic surgery and dermatologic oncology (MSDO) fellows and fellowship directors

Article References: O’Hagan, R., McGeough, O., Navrazhina, K., Elder, A., & Lewin, J. M. (2026). Trends in racial and ethnic diversity among micrographic surgery and dermatologic oncology (MSDO) fellows and fellowship directors. Archives of Dermatological Research, 318(1), Article 394. https://doi.org/10.1007/s00403-026-04866-3

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04866-3

Keywords: Mohs micrographic surgery, dermatologic oncology, MSDO fellowship, racial diversity, ethnic diversity, underrepresented in medicine, program directors, dermatology workforce, name-based ethnicity inference, health equity, skin cancer surgery, medical education

The research, led by J. Christopher Polanco-Santana of Beth Israel Deaconess Medical Center and Harvard Medical School, together with Alessandra Storino of UT Southwestern Medical Center, Daniel Wong, and senior author Tara S. Kent, builds on the team’s earlier work. In a previous study published in the Journal of Surgical Education, the same group demonstrated that ethnic and racial bias existed in the MSPEs of general surgery residency applicants when measured by the differential use of two categories of descriptive language: agentic and communal terms. Agentic words, such as assertive, confident, independent, and ambitious, describe traits associated with leadership, self-direction, and achievement. Communal words, such as caring, compassionate, helpful, and warm, describe traits associated with relationships and interpersonal connection. Decades of research in social psychology and organizational behavior have shown that agentic language tends to be associated with professional success, particularly in competitive and high-status fields like surgery, while communal language, though positive, is less often linked to perceptions of leadership and excellence.

What remained unknown after that earlier study was which portion of the MSPE was responsible for the biased word use. The MSPE is not a monolithic document. It contains multiple distinct sections, including a summary or evaluation section, often referred to as the structural portion, in which the writer distills the applicant’s overall performance into a synthesis and often a comparative statement about where the student stands relative to peers. Other portions include the academic history, professional performance evaluations organized by clerkship, and the applicant’s own noteworthy characteristics. Each section is written under different circumstances and may draw on different sources of information, which means that bias could, in principle, be concentrated anywhere in the document. Identifying the specific source matters enormously, because targeted interventions, whether in writer training, template design, or automated language screening, can only be effective if they are aimed at the right section.

To answer the question, the researchers conducted a retrospective study of all MSPEs submitted by applicants to categorical general surgery residency positions at a single academic institution across two consecutive Match cycles. The final dataset comprised 1,314 evaluations drawn from 146 different medical schools, giving the analysis a broad national sampling of how these documents are written across the United States. The two application cycles were comparable at baseline, and the gender distribution of the applicant pool was nearly even, with women making up 51.6 percent of applicants. Most applicants identified as white, accounting for 52.7 percent, or Asian, accounting for 25.3 percent, while 17 percent of applicants self-identified as underrepresented in medicine, a designation that includes racial and ethnic groups whose representation in the medical profession is disproportionately low relative to their share of the general population.

The methodological core of the study was the calculation of a bias score for each distinct portion of the MSPE. Rather than treating the document as a single block of text, the researchers computed separate scores reflecting the relative frequency of agentic versus communal terms in each section. They then used multivariable regression, a statistical technique that allows researchers to assess the association between an outcome and one predictor while accounting for the influence of other variables, to test whether each section-specific bias score differed between underrepresented-in-medicine applicants and non-underrepresented applicants. This approach isolates where in the document the differential language use arises, rather than merely confirming that it exists somewhere. The use of regression also helps guard against the possibility that observed differences are explained by confounding factors such as application cycle, medical school, or applicant characteristics.

The results were striking in their specificity. Applicants who identified as underrepresented in medicine had lower median overall bias scores, at 9.09, compared with white applicants, whose median overall bias score was 13.04. The same pattern appeared in the structural or summary portion of the document, where the median bias score for underrepresented applicants was 13.33 compared with 20 for white applicants. Because higher scores reflect a greater relative use of agentic language, these numbers indicate that the MSPEs of underrepresented-in-medicine applicants were written with systematically different word choices, leaning more heavily on communal descriptors and less on agentic ones. When the researchers examined the other sections of the document, the differential word use was concentrated in the summary portion, indicating that the structural or summary section is the primary source of the biased writing.

This finding carries real weight for the residency selection process. The summary section is arguably the most consequential part of the MSPE, because it is the portion that program directors most often read closely and cite when deciding whom to invite for interviews. Survey research from the National Resident Matching Program has shown that the MSPE is among the most influential documents in residency selection, and studies of program director behavior have found that the narrative evaluation can change decisions about whether to invite an applicant at all. If the language in the summary section systematically frames underrepresented-in-medicine applicants in more communal and less agentic terms, then even well-intentioned reviewers may absorb an implicit impression that these candidates are warm and dedicated but less commanding or leader-like than their peers. Such impressions, formed in seconds during application review, can compound across thousands of programs and contribute to the persistent underrepresentation of certain racial and ethnic groups in surgery.

The study also situates itself within a broader and rapidly growing literature on bias in evaluative language across medicine. Prior work has documented racial and ethnic disparities in clinical grading during medical school, gender-based differences in the language students use to describe their own noteworthy characteristics, and agentic and communal differences in letters of recommendation for applicants to radiology, urology, and surgical training programs. Researchers have shown that implicit racial bias among health care professionals influences clinical outcomes, that implicit bias affects admissions decisions, and that word embeddings trained on large text corpora can quantify decades of shifting gender and ethnic stereotypes in language. Some studies have explored whether redacting identifiers from applications can reduce biased scoring, while others have asked whether artificial intelligence tools could help mitigate bias in recommendation writing. The new study adds a crucial layer of granularity to this literature by demonstrating that bias is not diffusely spread through evaluative documents but is concentrated in the section where writers synthesize and summarize.

Why would the summary section be particularly vulnerable? The authors’ findings are consistent with what psychologists know about how stereotypes operate. When writers compile detailed evaluations from discrete clerkship assessments, they are largely transcribing and organizing specific observations, a task that anchors them to concrete performance data. When they write the summary, however, they must distill an entire career into a general characterization, and it is precisely in this act of abstraction that implicit associations are most likely to surface. The summary is also the section most likely to include comparative statements, ranking the applicant against peers, and comparative judgments are known to be especially sensitive to stereotype-driven expectations. Whatever the underlying mechanism, the practical implication is clear: interventions aimed at reducing bias in the MSPE should focus their attention on the summary and structural portion of the document, whether through structured templates, writer training that highlights agentic and communal language, or automated screening tools applied specifically to the final synthesis before the letter is released.

The researchers caution that their data, drawn from applicants to a single academic institution over two Match cycles, reflect one program’s applicant pool, and that the underlying data, obtained through the Electronic Residency Application Service and containing protected applicant information, are not available directly from the authors. Nevertheless, the scale of the sample, spanning 146 medical schools and more than 1,300 evaluations, lends considerable weight to the conclusion. The study was approved by the Institutional Review Board at Beth Israel Deaconess Medical Center and received no specific external funding. As surgery and medicine more broadly confront the persistent gap between the diversity of the population they serve and the homogeneity of their workforce, this research offers something rare in the field: a precise anatomical map of where bias hides in one of the most important documents in a physician’s career. Fixing the summary section, the study suggests, may be the single most efficient place to start.

Subject of Research: Ethnic and racial bias in the language of medical student performance evaluations for general surgery residency applicants

Article Title: Source of ethnic/racial bias in medical school performance evaluation of general surgery residency applicants

Article References: Polanco-Santana, J. C., Storino, A., Wong, D., & Kent, T. S. (2026). Source of ethnic/racial bias in medical school performance evaluation of general surgery residency applicants. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 130. https://doi.org/10.1007/s44186-026-00531-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00531-5

Keywords: MSPE, dean's letter, general surgery residency, ethnic bias, racial bias, agentic language, communal language, underrepresented in medicine, residency match, implicit bias, medical education, surgical workforce diversity

The research team, led by Sohail Khan of Touro College of Osteopathic Medicine together with collaborators at George Mason University, Stony Brook Medicine, Columbia University and other institutions, constructed a cross-sectional cohort of 892 directors. It included 179 medical student clerkship directors, 366 general surgery residency program directors, and fellowship directors in complex general surgical oncology, surgical critical care, minimally invasive surgery and endocrine surgery. Leadership identities were compiled from publicly available sources and national accreditation databases, including the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, the National Resident Matching Program and the American Medical Association’s FREIDA database, supplemented by the Fellowship Council and the American Association of Endocrine Surgeons.

Demographic characteristics were ascertained using automated facial analysis with investigator adjudication, an approach that has become increasingly common in workforce diversity research where self-reported race and gender data are unavailable for public-facing professionals. The team used the Betaface API, version 2.0, with human reviewers confirming classifications. Categorical comparisons relied on Pearson chi-squared and Fisher exact tests, while multivariable logistic regression identified factors independently associated with holding leadership roles. All analyses were performed in STATA version 18E. Because the study relied exclusively on publicly available, aggregated data with no patient-level or identifiable private information, institutional review board approval was deemed exempt.

The headline numbers are unambiguous. Among the 892 directors, White surgeons predominated at 67.8 percent, followed by Asian surgeons at 18.2 percent, Middle Eastern surgeons at 5.3 percent, Hispanic surgeons at 4.8 percent and Black surgeons at 3.9 percent. Female representation across the entire cohort stood at 34.5 percent, but the figure varied dramatically by subspecialty, a difference that reached statistical significance at P less than .001. Endocrine surgery led the way with 48.0 percent female fellowship directors, while minimally invasive surgery sat at the bottom with just 20.3 percent. Asian surgeons were most visible at the fellowship tier in complex general surgical oncology, at 31.4 percent, and endocrine surgery, at 24.0 percent, while international medical graduates were most prevalent among directors in complex general surgical oncology at 20.0 percent and minimally invasive surgery at 18.3 percent.

Perhaps the most revealing structural signal came from academic rank. Rank distribution differed markedly across leadership tiers, again with P less than .001. Assistant professors constituted the plurality of clerkship directors at 44.1 percent, suggesting that the entry point of the educational pipeline is staffed disproportionately by junior faculty. At the opposite end, full professors were most common among fellowship directors in complex general surgical oncology at 40.0 percent and minimally invasive surgery at 33.3 percent. Institutional setting followed a similar gradient: residency program directors were predominantly community-based at 58.8 percent, whereas fellowship directors were primarily university-based. In other words, as leadership roles become more senior and more concentrated in elite academic centers, they become demographically narrower.

The pipeline benchmarking makes the attrition vivid. Between 2022 and 2025, across 214,411 medical school applicants and 5,988 matched general surgery residents, women accounted for 56.8 percent of applicants and 55.1 percent of matched residents. Black trainees represented 9.4 percent of matriculants and 7.2 percent of matched residents, and Hispanic trainees 6.4 percent of matriculants and 12.0 percent of matched residents. Every one of those proportions exceeds the corresponding group’s share of surgical education leadership. Black surgeons, at 3.9 percent of directors, hold leadership roles at less than half their rate of residency entry. Hispanic surgeons, at 4.8 percent of directors, fare even worse against their 12.0 percent share of matched residents. Women, the statistical majority of incoming residents, remain a one-third minority of directors overall and barely one in five in minimally invasive surgery.

The authors frame this discordance as demographic consolidation within senior academic ranks and university-based institutions across the surgical training continuum. The mechanism is consistent with the well-documented leaky pipeline literature cited in the study, which traces how underrepresented-in-medicine trainees encounter compounding barriers from undergraduate education through faculty advancement. Prior work has shown that mentorship alone is insufficient without active sponsorship, that early-career scholarly productivity gaps set the stage for unequal academic advancement, and that leadership demographics of training programs are themselves associated with trainee diversity. A leadership tier that does not reflect the trainees beneath it risks perpetuating itself, since directors control recruitment, evaluation, promotion and the informal networks through which opportunities flow.

The timing of the study lends it particular urgency. The published literature it draws on includes recent warnings that health care has become a new battlefront for anti-diversity, equity and inclusion attacks, and that anti-DEI legislation threatens both equitable surgical care and workforce diversity. In that climate, the study’s demonstration that gains at the trainee level are not being converted into governance-level representation provides an empirical baseline against which any policy retreat or advance can be measured. It also matters for patients: prior research has linked surgeon sex to long-term postoperative outcomes for common operations, and a diverse physician workforce is associated with improved trust and communication among racially and ethnically diverse patient populations.

Methodologically, the continuum-wide design is what distinguishes this analysis from earlier single-tier studies. Previous investigations have examined gender gaps among residency program leadership, diversity within individual fellowship directorships, or racial trends in specific subspecialty pipelines, but few have connected clerkship, residency and fellowship leadership into a single cross-sectional frame and benchmarked each tier against national applicant and match data. That design exposes the gradient directly: diversity is highest where the pipeline is widest and lowest where the funnel is narrowest, with the fellowship director tier, the most university-concentrated and most senior, showing the greatest consolidation. The subspecialty contrasts are equally instructive, since endocrine surgery’s near-parity female leadership and complex surgical oncology’s relatively high Asian and international medical graduate representation demonstrate that different structural cultures within surgery produce different outcomes from the same national pipeline.

The study’s limitations are those inherent to its design. Facial analysis, even with investigator adjudication, is an imperfect proxy for self-identified race and gender, and the cross-sectional snapshot cannot establish causation or track individuals over time. The fellowship analysis covers four subspecialties rather than the full breadth of surgical fellowship training. Still, the data availability statement notes that all figures derive from publicly accessible sources and are included in the published article and its supplementary files, making the findings independently verifiable. What the analysis delivers is a precise, reproducible map of where the surgical education system loses its diversity, and the map points unambiguously to the terminal bottleneck: the senior, university-based directorships that shape who enters the profession, how they are trained, and who among them will one day hold the levers of surgical governance. Until representation at that tier reflects the majority-female, increasingly diverse residency cohorts now moving through the pipeline, the study suggests, the demographic gains of the past decade will remain stranded at the bottom of the ladder.

Subject of Research: Demographic and structural disparities in U.S. surgical education leadership across the training continuum

Article Title: The terminal bottleneck: a continuum-wide cross-sectional analysis of demographic and structural disparities in U.S. surgical education leadership (2025–2026)

Article References: Khan, S., Toro, D., Yu, Y., Cohen, H., Zuluaga, D., Betterbed, D., Luo, T., McAfee, G., Mahal, S., Yamada, A., Ojukwu, K., Ortiz, A. C., Koizumi, N., Wen, K., Parikh, A., Chijioke, W., Ijaz, S., Arrioja, L., Li, M.-H., & Ortiz, J. (2026). The terminal bottleneck: a continuum-wide cross-sectional analysis of demographic and structural disparities in U.S. surgical education leadership (2025–2026). Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 148. https://doi.org/10.1007/s44186-026-00548-w

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00548-w

Keywords: surgical education, leadership diversity, academic surgery, workforce disparities, gender equity, underrepresented in medicine, fellowship directors, residency program directors, clerkship directors, leaky pipeline, medical education, health equity

The ASPIRES Program, short for Advancing Student Preparedness and Involvement for Representation and Equity in Surgery, was established at Duke to address a persistent pipeline problem. Longitudinal studies have documented declining racial and ethnic representation across 16 US clinical academic specialties, and national analyses of general surgery residency programs show that underrepresented minorities remain a small fraction of trainees. Prior research has linked this shortfall to disparities in mentorship access, which several studies identify as a decisive factor in whether underrepresented students pursue surgical careers at all.

To understand what students actually want from such a program, the research team turned to a simple but powerful data source. At the start of the program, every participant answered the question: Why are you interested in participating in ASPIRES? The team collected 73 de-identified responses across four cohorts from 2021 to 2024, achieving a 100 percent response rate. The respondents were predominantly Black or African American at 65 percent, with 35 percent identifying as Latinx or Hispanic and 64 percent as women, providing a demographic portrait of the students these pipeline initiatives are designed to reach.

The analytical approach followed established qualitative methodology. Two independent reviewers coded the responses using NVivo 14 software and a 26-factor thematic codebook developed iteratively as patterns emerged from the text. When the reviewers disagreed on how a passage should be coded, they resolved the discrepancy by consensus. This kind of thematic analysis is a standard tool in medical education research, allowing investigators to move beyond surface statements and identify the underlying drivers of student behavior across a large body of free-text responses.

Five core motivators emerged from the analysis: mentorship, preparation, exposure, career facilitation, and environment. The most frequently cited theme was mentorship itself, appearing in 63 percent of responses, followed by career preparation at 44 percent and a desire for representation or community at 41 percent. Roughly one in three students said they wanted early exposure and opportunities to explore surgical careers. In other words, students were not primarily asking for handholding; they were seeking relationships, roadmap knowledge, and a sense that people like them belong in the operating room.

Equally instructive were the themes that barely registered. Only 6.7 percent of students cited experiential learning as a motivation, and just 13.3 percent mentioned wanting insight into navigating the so-called hidden curriculum, the unspoken norms, networks, and expectations that often determine success in academic medicine. For program designers, this suggests students may not yet recognize how much of the professional socialization process is invisible to them, or they may prioritize visible resources like faculty contact over subtler forms of guidance during the first year.

The study’s central conclusion is one of reassurance: what students sought aligned closely with what ASPIRES was built to provide. That alignment matters because mismatched expectations are a known failure mode in mentorship. When a program promises skill development but students arrive seeking belonging, or vice versa, both mentors and mentees can end up frustrated. Here, the emphasis on identity-conscious mentorship, meaning mentorship that explicitly centers shared identity and belonging rather than treating it as an afterthought, appears to meet students exactly where they are.

The findings sit within a broader and growing evidence base. A 2026 systematic review in the American Journal of Surgery examined the availability of mentorship for underrepresented minorities in surgery and surgical subspecialties, while other studies have shown that structured mentorship programs can improve surgical residency match rates for underrepresented learners. Related initiatives such as LEAGUES, which focuses on leadership exposure for gender and minority equity in surgery, and a four-year follow-up of a preclinical mentorship and early exposure program published in the same journal, reinforce the idea that sustained, structured pipelines can move the needle on representation.

Why does surgical diversity matter beyond the profession itself? Prior research indicates that minority physicians are more likely to care for underserved patients, suggesting that a diversified surgical workforce could play a direct role in addressing health disparities. Meanwhile, the literature on stereotype threat documents how women and minorities exit science and medicine pathways when environments fail to signal belonging. Pipeline programs that combine technical preparation with community-building attack the problem from both ends at once, which may explain why the students in this study overwhelmingly valued representation alongside mentorship.

The Duke team concludes that ASPIRES represents a promising and scalable model for advancing equity in surgical education, and the data support that optimism: a complete response rate across four cohorts, clear thematic demand, and demonstrated alignment with program goals. The challenge ahead is replication and scale. If other institutions can adopt similar identity-conscious mentorship structures and measure student expectations as rigorously, the long path from first-year lecture hall to operating suite may become measurably more navigable for the students surgery has historically left behind.

Subject of Research: Motivations of first-year underrepresented medical students joining a surgical mentorship pipeline program

Article Title: First-year medical students’ motivations for joining an underrepresented minority mentorship program: are we meeting expectations?

Article References: Yanez, G., Soto, A. L., Zasloff, R. A., Mensah-Mamfo, M., Odei, A. D., Gomes, P. V., Medina, C. K., Reeves, R., Eward, W. C., DiLalla, G. A., & Vatsaas, C. J. (2026). First-year medical students’ motivations for joining an underrepresented minority mentorship program: are we meeting expectations?. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 159. https://doi.org/10.1007/s44186-026-00560-0

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00560-0

Keywords: mentorship, underrepresented in medicine, surgery, medical education, pipeline programs, ASPIRES, thematic analysis, health equity, Duke University, surgical careers, representation, hidden curriculum

The findings, led by Neil S. Zhang and Atif Qasim of the University of California, San Francisco, along with collaborators at Creighton University and the Kirk Kerkorian School of Medicine at UNLV, are striking in their clarity. Overall, 32,091 of the 38,179 applicants, or 84.1 percent, successfully entered the subspecialty to which they applied. But that aggregate success rate conceals dramatic differences among applicant groups. Research productivity emerged as the single most powerful predictor: applicants with 11 or more publications had 4.18 times higher odds of success compared with those who had none, a stronger association than any other characteristic examined.

The study leveraged a unique combination of databases. Applicant characteristics came from the Electronic Residency Application Service, or ERAS, administered by the Association of American Medical Colleges, and were linked to the AAMC’s Graduate Medical Education Track, a national registry of trainees at every residency and fellowship program. An applicant was defined as successful if he or she appeared in GME Track as a fellow in the same subspecialty during the corresponding appointment year. The researchers excluded applicants who applied to more than one subspecialty, applied in multiple years, or had masked ages, yielding a cohort of single-time applicants to cardiovascular disease, endocrinology, gastroenterology, hematology and oncology, infectious disease, pulmonary and critical care medicine, nephrology, and rheumatology.

Statistically, the team used multivariable logistic regression to isolate the effect of each characteristic while adjusting for all others, along with the subspecialty and application year. Predictive margins were estimated to calculate adjusted probabilities of success for different applicant groups across publication categories. The cohort had a median age of 31 years, and 41.2 percent were female, 9.5 percent identified as underrepresented in medicine, and 39.6 percent were international medical graduates. Chief resident status, additional graduate degrees such as a PhD or master’s degree, and training in larger residency programs with 55 or more residents all independently boosted the odds of success.

Against these advantages, several groups faced measurable headwinds. Each additional year of age was associated with lower odds of success. After adjustment, female applicants had 0.89 times the odds of success, underrepresented-in-medicine applicants 0.84 times, osteopathic DO graduates 0.53 times, and international medical graduates just 0.44 times the odds of their counterparts. Graduates of community-based residency programs and community-based, university-affiliated programs were likewise significantly less likely to succeed than those from university-based programs, a pattern the authors attribute in part to the weight program directors place on the perceived reputation of the training institution.

The subspecialty-level breakdown sharpened the picture. The disadvantage for female applicants was most pronounced in cardiovascular disease and gastroenterology, where women had 0.79 times the odds of success, while the penalty for underrepresented-in-medicine applicants was especially evident in pulmonary and critical care medicine, at 0.59 times the odds. The payoff for research output also varied: the association between 11 or more publications and success was particularly strong in gastroenterology, pulmonary and critical care medicine, and endocrinology, though notably absent in infectious disease. Analyses restricted to the four most competitive subspecialties suggested that many of these disadvantages grew even larger in the toughest markets.

One of the most consequential findings concerns whether publications can compensate for baseline disadvantage. Predictive margins showed that success rose with publication count for every applicant group. For underrepresented-in-medicine applicants, the gap with non-underrepresented peers appeared to narrow at higher publication counts, although interaction testing did not reach statistical significance, likely because few such applicants reached the highest publication category. More sobering was the finding that the disadvantages experienced by female and DO applicants persisted at every level of research productivity, showing no attenuation whatsoever. International medical graduates gained more from each additional publication than their MD counterparts, yet even this larger benefit failed to erase their baseline gap entirely.

The authors frame these results as evidence of a self-reinforcing research arms race. Program director surveys consistently rank research involvement and perceived interest in scholarship among the most important selection factors, prompting applicants to accumulate ever more publications, which in turn pushes programs to value the metric even more. Prior work suggests many of these entries are never cited, raising concerns about the quality of the science behind the numbers. The ERAS publications variable aggregates journal articles, abstracts, book chapters, and presentations into a single count, so a first-author paper in a major journal currently carries the same statistical weight as a poster at a regional meeting, a limitation the researchers say should be addressed in future studies.

As a remedy, the study advocates for Mission-aligned Selection, a framework promoted by the AAMC that emphasizes individualized, systematic review of applicants’ experiences, attributes, and academic metrics in light of each program’s mission. Early adopters offer encouraging signals: after one pulmonary and critical care fellowship implemented holistic review practices, its faculty ranked publications among the least important metrics, and a pediatric surgery fellowship reported that the caliber of its interviewees actually improved. The authors also point to preference signaling, now available in several internal medicine subspecialties, as a tool that may reduce defensive over-application, though its effects on equity remain unproven. They caution that qualitative materials central to holistic review, such as letters of recommendation, have been shown to contain biased language toward female and underrepresented applicants, so standardization efforts must accompany any shift away from raw publication counts.

The study’s limitations are worth noting. Because direct match data were not available, success was defined as entering the subspecialty rather than formally matching, though out-of-match placements likely represent a small minority. Factors such as board scores, honors, interview ratings, and personal statements were unavailable, leaving room for residual confounding. Still, as the first comprehensive, individual-level national analysis of its kind, the work makes the structure of the fellowship selection process unusually visible. Its message is twofold: research output overwhelmingly determines who gets in, and the system as currently constituted systematically favors younger, male, non-underrepresented, US MD graduates at large university programs. Whether programs and their governing bodies embrace mission-aligned processes may determine not only individual careers but also the future diversity and representativeness of the internal medicine subspecialty workforce.

Subject of Research: Factors associated with successful entry into internal medicine subspecialty fellowships

Article Title: Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships

Article References: Zhang, N. S., Tun, K. M., Batra, K., Babik, J. M., Huppert, L., Singh, A., Wahi-Gururaj, S., & Qasim, A. (2026). Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10688-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10688-w

Keywords: internal medicine, fellowship match, graduate medical education, publications, underrepresented in medicine, international medical graduates, osteopathic medicine, mission-aligned selection, ERAS, cardiology, pulmonary critical care, workforce diversity